Nomination for inclusion in the National Advisory and Interim by 3s0SZiA

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									Application to join the NHS Interim Management and Support
NHS pool
(By agreeing to be on the register, you will agree to NHS IMAS sharing the information on this form with other
NHS organisations as and when requested)

Personal Details
Name:
Telephone:
Email address:
Current grade & salary:



Name three pieces of work you’ve been involved in?
1.


2.



3.




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What were the challenges and what was your contribution on the
above?




What do you concentrate on/specialise in?




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Availability/mobility
Please provide any information regarding availability, mobility etc. Please update us if this
changes.




Please specify if you have been either referred from or have previously
attended the leadership Programmes below :-
National Programmes

        Top Leaders
        Breaking Through
        Gateway to Leadership
        Clinical Fellowship


Regional/SHA Programme

        Aspiring Chief Executives
        Executive Stretch
        Aspiring Directors

Other:




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Supporting references
You must provide the names and contact details (including email address) of three recent
NHS referees, one of which must be your current Line Manager (please highlight who this
is).
We will contact your referees direct in order to complete the registration process.




How did you hear about NHS IMAS? (Please select one option)
Website
Word of mouth
NHS IMAS Partner
Previous client
NHS IMAS IST Team
Another NHS IMAS pool member / colleague
SHA mailshot
Regional publications – which one?




Please enclose a copy of your CV.




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