MRCF Dentists' Study Group

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					                     MRCF Dentists’ Study Group
                        Membership Form

Personal Details
GDC Registration/                                   Defence Union
Reference Number:                                   Number:

GDC Registration status (limited, full,
unregistered, eligible, provisional):

First name:                                         Surname (Family
                                                    name):

Address:


Postcode:                                           Borough:


Telephone number &                                  E-mail:
Mobile:

Male/Female:                                        Date of Birth:


Marital status:                                     Age:


Dependents (elderly                                 First language:
/children etc.):

Nationality:                                        Country of origin:


Year of entry into                                  Ethnic origin:
UK:

Immigration status (e.g. refugee, ILR, ELR,
British citizen, dependent visa etc.). Please
put “refugee” if originally granted refugee
status:

Financial situation (NASS, employed, benefits
– JSA, income support, incapacity benefit,
disability living allowance etc.):



                                                1
Dental Qualifications and Training
Title:                                           Date of
                                                 qualification:

Country of initial                               University:
dental qualification:

Other Qualifications:
Year:                                            Awarding body:




Language of initial                              Languages
training:                                        spoken:

Dental speciality:                               Years in
                                                 speciality:

Years since last
practiced:



UK Registration Process (please include date and scores including failed attempts and
future exams)

IELTS
No. of times taken IELTS: __________________

Date          Listening     Reading         Writing            Speaking      Total Score




Study Groups or courses attended to help with IELTS preparation (please put name of
organisation & type of organisation: i.e. university, Further Education college, voluntary
organisation etc.):
Name of organisation                           Type of organisation




                                             2
ORE
                           Date                       Pass/Fail/To sit
ORE part 1

ORE part 2


Study Groups or courses attended to help with IQE preparation (please put name of
organisation & type of organisation: i.e. university, Further Education college, voluntary
organisation etc.):
Name of organisation                           Type of organisation




All Work history in UK
Dates                          Title of Job                    Employer
From – To




Clinical attachments in UK
Dates                      Speciality                          Institution
From – To




Further information and requirements (childcare/disability/other support needs etc)




How did you hear about our study group: (please circle) friend/website/BDA/GMC/
other:……………………………………………………………………………………………………………………

I agree to abide by the terms of the dentists’ study group and provide copies of two
forms of ID (1 academic ID [copy of degree] and 1 identity ID [passport copy, drivers

                                              3
licence etc.]). I declare that all the details given on this form are true to the best of my
knowledge.

Signed                                                           Date

Data protection act 1998 – The information you have provided is confidential and will only be used for the
MRCF dentists’ study group and the London wide evaluation database for refugee dentists’ programmes.
This information will not be given to any other organisations/individuals without the consent of the
individual.
                                Please return this form to:
                                        Sofia Aman
                          MRCF, 2 Thorpe Close, London, W10 5XL

Official use only

Two forms of ID provided                        
Individual entered to database                  

Signed                                                           Date
                                                                                  Form updated 14/08/2009




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