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Application Form 2011 (DOC)

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					SHO Rotation Programmes 2011
APPLICATION FORM

                           DO NOT ATTACH THIS PAGE TO YOUR APPLICATION!


                                              IMPORTANT NOTICE

     This is the application form for SHO Rotation Programmes in General Internal Medicine, Paediatrics,
      Obstetrics and Gynaecology, and Histopathology, commencing 11 July 2011.
     Only information contained on this application form will be taken into consideration by short-listing panels.
      Do not submit a copy of your Curriculum Vitae.
     Incomplete and or late applications will be returned.
     An application will be considered incomplete if all the information requested has not been provided, or if it
      does not include properly certified copies of supporting documents.
     The closing date for receipt of applications is 5.00pm Friday 14 January 2011.



                                                HOW TO APPLY

  1. Hold your cursor over the relevant sections of this form and type directly onto it.
  2. Save your completed application form (as a Word document, .doc or .docx) to your computer.
  3. Submit your application form online by clicking on the link on the SHO Matching Scheme home page and
      attaching your document. Do NOT email it to RCPI. You will receive an acknowledgement email from RCPI
      with your unique application number.
  4. Print your application form, sign it, include the application number supplied in your acknowledgement email
      and post one copy per specialty to RCPI, along with one full set of supporting documents per specialty.
      Supporting documents to be enclosed with printed Application Form, per specialty:
          o   1 certified copy of your current Medical Council (Ireland) Certificate of Registration or alternative
              documentation as specified on the RCPI website.
                                                              st
          o   1 certified copy of transcript of exam results (1 year – final year) from Medical School/University
          o   1 certified copy of other degrees/diplomas (if applicable)
          o   Application Fee of €100 (non refundable) per programme, up to a maximum of €400 in total. When
              you apply online, you will receive automatic notification of the total application fee due.
          o   2 passport-sized photographs



                                RETURN ADDRESS AND CONTACT DETAILS

      BST Office                                         Email: shomatch@rcpi.ie
      RCPI                                               Phone: 01 8639 711 or 01 8639 715 or 01 8639 710
      19 South Frederick Street                          Fax: 01 672 4707
      Dublin 2                                           Office hours: 9.00am – 5.00pm, Mon – Fri
SHO Rotation Programmes 2011
APPLICATION FORM

                                  Application Coversheet (Page 1)
 Please attach the following two pages securely to your printed application form
                    This coversheet will not be made available to hospitals or short-listing panels

                            Please indicate which programmes you are applying for.
 General Internal Medicine:
 Beaumont Hospital, Dublin - TWO YEAR                                                    ''Type YES or NO''
 Bon Secours Hospital, Cork – ONE YEAR                                                   ''Type YES or NO''
 Cavan/Monaghan – ONE YEAR                                                               ''Type YES or NO''
 Connolly Hospital, Blanchardstown, Dublin – ONE YEAR                                    ''Type YES or NO''
 Connolly Hospital, Blanchardstown, Dublin – TWO YEAR                                    ''Type YES or NO''
 Cork University Hospital Medical SHO Rotation Programme - TWO YEAR                      ''Type YES or NO''
 Galway University Hospital & Merlin Park Hospital – ONE YEAR                            ''Type YES or NO''
 Galway University Hospital & Merlin Park Hospital – TWO YEAR                            ''Type YES or NO''
 Letterkenny General Hospital, Donegal – ONE YEAR                                        ''Type YES or NO''
 Louth/Meath – ONE YEAR                                                                  ''Type YES or NO''
 Mater Misericordiae University Hospital, Dublin – ONE YEAR                              ''Type YES or NO''
 Mater Misericordiae University Hospital, Dublin – TWO YEAR                              ''Type YES or NO''
 Mayo/Galway/Roscommon – ONE YEAR                                                        ''Type YES or NO''
 Midland Regional Hospitals – ONE YEAR                                                   ''Type YES or NO''
 Mid-Western Regional Hospital (Limerick) – TWO YEAR                                     ''Type YES or NO''
 Munster Hospitals Rotation Programme – ONE YEAR                                         ''Type YES or NO''
 Munster Hospitals Rotation Programme – TWO YEAR                                         ''Type YES or NO''
 Sligo General Hospital – ONE YEAR                                                       ''Type YES or NO''
 South East (Kilkenny, Clonmel, Wexford) – TWO YEAR                                      ''Type YES or NO''
 South Infirmary-Victoria University Hospital – ONE YEAR                                 ''Type YES or NO''
 St Columcille's Dublin / Wexford General Hospital – TWO YEAR                            ''Type YES or NO''
 St Vincent’s University Hospital, Dublin – TWO YEAR                                     ''Type YES or NO''
 The Trinity Scheme (St. James's Hospital/Tallaght), Dublin – ONE YEAR                   ''Type YES or NO''
 The Trinity Scheme (St. James's Hospital/Tallaght), Dublin – TWO YEAR                   ''Type YES or NO''
 Waterford Regional Hospital – TWO YEAR                                                  ''Type YES or NO''
 Obstetrics and Gynaecology (National programme) – ONE/TWO YEAR                          ''Type YES or NO''
 Paediatrics (National programme) – ONE YEAR                                             ''Type YES or NO''
 Paediatrics (National programme) – TWO YEAR                                             ''Type YES or NO''
 Histopathology (National programme) – ONE/TWO YEAR                                      ''Type YES or NO''
                                   Application Coversheet (Page 2)
                     This coversheet will not be made available to hospitals or short-listing panels

                                                  Application Number
                     This number is emailed to you after you submit the application form online

  Write your Application Number here (can only be written by hand): ………………………………………….........


                                              Conditions of Participation

  Have you ever been convicted of a criminal offence in Ireland or any other country, or do
                                                                                                       ''Type YES or NO''
  you have any hearings pending? If yes, please give details on a separate sheet

  I have read the Conditions of Participation for Candidates, as outlined on www.rcpi.ie, and I agree to adhere
  fully to these conditions.


  Signed: …………………………………………………………………………………………Date:.……………………

                                                   Other Information
  Do you have a disability?                                                                            ''Type YES or NO''

  Please confirm that you understand that an offer on to the training programme may be
                                                                                                       ''Type YES or NO''
  subject to the satisfactory completion of an occupational assessment.

                                                 Application Checklist

  Please indicate what supporting documents you are enclosing with your application to each specialty.
  1 certified copy of Medical Council Certificate of Registration or alternative document              ''Type YES or NO''
  1 certified copy of transcript of exam results from your Medical School/University                   ''Type YES or NO''
  1 certified copy of other degrees/diplomas (if applicable)                                           ''Type YES or NO''
  Application Fee                                                                                      ''Type YES or NO''
  2 passport-sized photographs                                                                         ''Type YES or NO''
  Printed and signed copy of Application Form (including coversheets)                                  ''Type YES or NO''

I confirm that the information contained in this application form is complete, accurate and current to the best of my
knowledge. I understand that any information contained in this form may be held on a computer.

If my application is successful, I understand that this application form and my appraisal forms will be made available
to the SHO rotation programme to which I am matched.


Signed: …………………………………………………………………………………………Date: ……………………...

                                                  Credit Card Details
                       If you want to pay the Application Fee by credit card, please complete this section


          
Card Number


Visa  MasterCard  Expiry Date  


Amount € ___________________ Signature _____________________________________________
SHO Rotation Programmes 2011
APPLICATION FORM


                                                 Personal Details
 Surname                                 ''Click here and type Surname''
 First name                              ''Click here and type Forename''
 Date of Birth                           ''DD / MM / YR''
 Address (secure)                        ''Click here and type Address''
                                         ''Address line 2''
                                         ''Address line 3''
                                         ''County''
                                         ''Country''
 Home phone number                       ''xxxxxxxxxxxxxxxxxx''
 Work phone number, including bleep      ''xxxxxxxxxxxxxxxxxx''
 Mobile phone number                     ''xxxxxxxxxxxxxxxxxx''
 Email Address                           ''Click here and type Email Address''
                                      Current Medical Council Registration
 Medical Council of Ireland              ''Type YES or NO''
 General Medical Council UK*             ''Type YES or NO''
 Name in which you are registered        ''Click here and type Name''
 Registration Number                     ''xxxxxxxxxxxxxxxxxx''
                                                Education Details
 Medical School/University Name          ''Click here and type School/University''
 School/University City and Country      ''Click here and type city and country''
 Primary Medical Qualification           ''Click here and type Qualification''
 Date of Entry to medical school         ''DD / MM / YR''
 Date of Graduation                      ''DD / MM / YR''
                                            Final Year Exam Results
     1. ''Click here and type subject and grade''
     2. ''Click here and type subject and grade''
     3. ''Click here and type subject and grade''
     4. ''Click here and type subject and grade''
     5. ''Click here and type subject and grade''
     6. ''Click here and type subject and grade''
     7. ''Click here and type subject and grade''
     8. ''Click here and type subject and grade''
     9. ''Click here and type subject and grade''
     10. ''Click here and type subject and grade''
                                        Honours in Undergraduate Subjects
Number of Honours in Undergraduate Subjects: ''Type number of honours''
Subject: ''Type Subject''                 Subject: ''Type Subject''           Subject: ''Type Subject''
Year: ''Type year''                       Year: ''Type year''                 Year: ''Type year''
Subject: ''Type Subject''                 Subject: ''Type Subject''           Subject: ''Type Subject''
Year: ''Type year''                       Year: ''Type year''                 Year: ''Type year''
Subject: ''Type Subject''                 Subject: ''Type Subject''           Subject: ''Type Subject''
Year: ''Type year''                       Year: ''Type year''                 Year: ''Type year''
Subject: ''Type Subject''                 Subject: ''Type Subject''           Subject: ''Type Subject''
Year: ''Type year''                       Year: ''Type year''                 Year: ''Type year''
Subject: ''Type Subject''                 Subject: ''Type Subject''           Subject: ''Type Subject''
Year: ''Type year''                       Year: ''Type year''                 Year: ''Type year''
Subject: ''Type Subject''                 Subject: ''Type Subject''           Subject: ''Type Subject''
Year: ''Type year''                       Year: ''Type year''                 Year: ''Type year''
Subject: ''Type Subject''                 Subject: ''Type Subject''           Subject: ''Type Subject''
Year: ''Type year''                       Year: ''Type year''                 Year: ''Type year''
                                            Other Relevant Qualifications
   Qualification/Degree/Diploma                      Awarding Body                    Date of Qualification
''Click here and type Qualification''            ''Type Awarding Body''                 ''DD / MM / YR''
''Click here and type Qualification''            ''Type Awarding Body''                 ''DD / MM / YR''
''Click here and type Qualification''            ''Type Awarding Body''                 ''DD / MM / YR''
                       Postgraduate Exams or Courses                                          Date
               ''Click here and type name of exam or course''                           ''DD / MM / YR''
               ''Click here and type name of exam or course''                           ''DD / MM / YR''
               ''Click here and type name of exam or course''                           ''DD / MM / YR''
               ''Click here and type name of exam or course''                           ''DD / MM / YR''
                                        Undergraduate Academic Distinctions

                         Please give details of any prizes, medals or scholarships received




''Click here to start Typing''




                                        Postgraduate Academic Distinctions

                         Please give details of any prizes, medals or scholarships received




''Click here to start Typing''
                                    Publications, Audit and Presentations
Only complete these sections if they are applicable to you. Do not delete any pages. If you have more than one entry
per category, copy and paste the relevant sections as needed.

                                                        Publication
   Full descriptive title of published abstract        ''Click here to start Typing''
   Published in National Journal                       ''Type YES or NO''
                                      st
   Published in National Journal – 1 Author            ''Type YES or NO''
   Published in International Journal                  ''Type YES or NO''
                                            st
   Published in International Journal – 1 Author       ''Type YES or NO''
   Authors (Initial and surname only, no titles)       ''Click here to start Typing''
   Department(s), Institution(s), city(ies), country   ''Click here to start Typing''
   Name of journal                                     ''Click here to start Typing''
   Volume and page number                              ''Click here to start Typing''
   Publication date                                    ''DD / MM / YR''
                                                       Abstract Text

                                            Please paste your abstract text here




   ''Click here and paste abstract text''
                                                          Audit
Full descriptive title of audit                       ''Click here to start Typing''
Completed audit (unpublished)                         ''Type YES or NO''
Published in National Journal                         ''Type YES or NO''
                                   st
Published in National Journal – 1 Author              ''Type YES or NO''
Published in International Journal                    ''Type YES or NO''
                                        st
Published in International Journal – 1 Author         ''Type YES or NO''
Authors (Initial and surname only, no titles)         ''Click here to start Typing''
Department(s), Institution(s), city(ies), country     ''Click here to start Typing''
Name of journal (if published)                        ''Click here to start Typing''
Volume and page number (if published)                 ''Click here to start Typing''
Publication date (if published)                       ''DD / MM / YR''
                                                    Summary of Audit

                                             Please describe your Audit here




''Click here and start typing''
                                                     Presentation

                 Only a presentation at a National or International Meeting may be included here
Full descriptive title of presentation               ''Click here to start Typing''
Presented at National Meeting                        ''Type YES or NO''
Poster presentation at National Meeting              ''Type YES or NO''
Presented at International Meeting                   ''Type YES or NO''
Poster presentation at International Meeting         ''Type YES or NO''
Authors (Initial and surname only, no titles)        ''Click here to start Typing''
Name of meeting                                      ''Click here to start Typing''
Location                                             ''Click here to start Typing''
Presentation date                                    ''DD / MM / YR''
                                             Summary of Presentation 1

                                         Please describe your presentation here




''Click here and start typing''
                                                            Employment History

     Beginning with the most recent, list all previous appointments up to and including your present appointment
                   Hospital
                                                             Grade              Specialty            From – To             Months in post
      If overseas please indicate country
                                                                                                     01/07/04 –
         Example: St. James’s Hospital                        Intern             Surgery                                             6
                                                                                                      31/12/04
                                                                                                    ''dd/mm/yr''-
       ''Click here and type Information''                  ''Grade''          ''Speciality''                                      ''xx''
                                                                                                     ''dd/mm/yr''
                                                                                                    ''dd/mm/yr''-
       ''Click here and type Information''                  ''Grade''          ''Speciality''                                      ''xx''
                                                                                                     ''dd/mm/yr''
                                                                                                    ''dd/mm/yr''-
       ''Click here and type Information''                  ''Grade''          ''Speciality''                                      ''xx''
                                                                                                     ''dd/mm/yr''
                                                                                                    ''dd/mm/yr''-
       ''Click here and type Information''                  ''Grade''          ''Speciality''                                      ''xx''
                                                                                                     ''dd/mm/yr''
                                                                                                    ''dd/mm/yr''-
       ''Click here and type Information''                  ''Grade''          ''Speciality''                                      ''xx''
                                                                                                     ''dd/mm/yr''
                                                                                                    ''dd/mm/yr''-
       ''Click here and type Information''                  ''Grade''          ''Speciality''                                      ''xx''
                                                                                                     ''dd/mm/yr''
                                                                                                    ''dd/mm/yr''-
       ''Click here and type Information''                  ''Grade''          ''Speciality''                                      ''xx''
                                                                                                     ''dd/mm/yr''
                                                                                                    ''dd/mm/yr''-
       ''Click here and type Information''                  ''Grade''          ''Speciality''                                      ''xx''
                                                                                                     ''dd/mm/yr''
                                                                                                    ''dd/mm/yr''-
       ''Click here and type Information''                  ''Grade''          ''Speciality''                                      ''xx''
                                                                                                     ''dd/mm/yr''
                                                           Additional Information

   Use this section to highlight non-academic information about yourself that you consider relevant, for example: electives,
   volunteer work, sporting, creative or musical achievements, non-academic awards. Do not leave this section blank, but
   keep it concise and factual; you will have the opportunity to elaborate at the interviews.




   ''Click here and start typing''




                                                                    Referees
   Please provide the name of your CURRENT supervising consultant and one other Consultant with whom you have worked.
   Do NOT include details of consultants with whom you worked prior to graduation or in a supernumerary/clinical attachment
   capacity.
             Full Name                            Job Title                         Hospital, City                      Email Address
   ''Type Name''                       ''Type Job Title''                   ''Type Hospital and City''          ''Type Email address''
   ''Type Name''                       ''Type Job Title''                   ''Type Hospital and City''          ''Type Email address''

* The College will only accept GMC registration certificates from applicants who are currently in their F1 year (equivalent to intern year) in Great
Britain or Northern Ireland. All applicants at a more senior grade (F2, SHO, etc) must be registered with the Medical Council of Ireland.

                                                                    LAST PAGE

				
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