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Foundation Fellowship Application Form V1.0




                     FOUNDATION FELLOWSHIP APPLICATION FORM

This application form is ONLY for use by medical practitioners holding a substantive or
honorary NHS or Defence Medical Services consultant post in the United Kingdom with
sessional or other contracted clinical commitment to Intensive Care Medicine applying for
Foundation Fellowship of the Faculty of Intensive Care Medicine. This also includes
consultants who have now retired but held this post on 1 January 2010.

The application form must be submitted in both hard copy and electronically. Please
complete in full using the electronic version of the document. Do not alter the format.

Submit the electronic copy to ficm@rcoa.ac.uk. Large applications should be electronically
zipped before sending. The submission will be acknowledged by return email.

Submit the hard copy to ‘Foundation Applications, The Faculty of Intensive Care Medicine,
Churchill House, 35 Red Lion Square, London WC1R 4SG’.

Please read the guidelines in this form carefully and note the supporting documentation
required for your application to be considered.


 Part 1            Contact and reference details
1.1 Title        1.2 First name(s)                           1.3 Last name
  Dr              Alexander Timothy                           Dewhurst

1.4 Address and postcode                                     1.5 Telephone number (Home)
  123 Kyverdale Road                                          02088062657
  London
  N16 6PS                                                    1.6 Telephone number (Work)
                                                              07956475523

1.7 Gender       1.8 Date of birth    1.9 Email address
 Male             25/01/1964           adewhurst@nhs.net

1.10 College number                                       1.11 Mobile number
 319603                                                   07956475523

1.12 Specialty                                            1.13 GMC number
 Anaesthesia                                              3925148


                                                                                            Page 1 (of 4)
Foundation Fellowship Application Form V1.0



 Part 2           Qualifications
2.1 Primary Medical Qualification      2.2 University you qualified from
  MBBS                                   London, Royal Free Hospital School of Medicine

2.2 Main Medical Qualification (please select from list below)

    FRCA (Royal College of Anaesthetists)
    MRCP (Royal College of Physicians of Edinburgh)
    MRCP (Royal College of Physicians of London)
    MRCP (Royal College of Physicians and Surgeons of Glasgow)
    MRCS (Royal College of Physicians and Surgeons of Glasgow)
    MRCS (Royal College of Surgeons of Edinburgh)
    MRCS (Royal College of Surgeons of England)
    FCEM (College of Emergency Medicine)

2.3 If you have further affiliate Colleges in addition to the College you received your Main
    Medical Qualification from, please note below




 Part 3           Application information
3.1 Details of your honorary or substantive       3.2 Number of sessions or other contracted
    consultant post in the United Kingdom             clinical commitment per week devoted
    including your full work address                  to Intensive Care Medicine

 Consultant Anaesthetist with Specialist            2 sessions per week
 Interest in Cardiothoracic Anaesthesia
 and Intensive Care
 St George’s Hospital
 Blackshaw Road
 London SW17 0QT



3.3 Please list any additional qualifications (e.g. Diploma, BSc etc.)
 Diploma in Economics Open University




3.4 Are you in good standing (i.e. are you up to date on your subscriptions) with your
    College?  Yes  No

For Fellows and Members of the Royal College of Anaesthetists only:

3.5 Are you willing to pay the subscription to the Faculty of Intensive Care Medicine via
    your existing direct debit to the College?  Yes  No


                                                                                             Page 2 (of 4)
Foundation Fellowship Application Form V1.0




 Part 4           Applicant’s Declaration


 I wish to have my application for the Foundation Fellowship of the Faculty of Intensive
 Care Medicine considered by the Board of the Faculty of Intensive Care Medicine.

 I enclose the following documentation:

         Completed and signed application form
         Completed Clinical Director Certificate (Appendix A)

 I agree that the Board of the Faculty of Intensive Care Medicine may seek any further
 information that it considers is relevant to my application, and that my personal details
 may be made available to a third party(ies), as required, for the purposes of considering
 my application.

 I understand that before an assessment of my application can proceed, the Clinical
 Director Certificate must have been received by the Board.

 I confirm that, to the best of my knowledge, all of the information that I have provided
 in this application represents a true and accurate statement. I understand that any
 serious misrepresentation or false information supplied with the intention to mislead is
 a probity issue that may be reported to the GMC.

 I agree that the information provided by me may be processed, in accordance with the
 Data Protection Act, for legitimate purposes connected with my application.


4.1 Name of applicant                           4.2 Signature of applicant*
 A Dewhurst

                                                       Signed by: Alexander Dewhurst
                                                       Date & Time: 15 Feb 2011 12:41:29 PM

                                                4.3 Date declaration signed
                                                  11/2/2011



* Signature of applicant: Please either include an electronic signature or print this page
  out, sign it in hard copy and scan it for submission electronically.




                                                                                                Page 3 (of 4)
Foundation Fellowship Application Form V1.0




 Appendix A                CLINICAL DIRECTOR CERTIFICATE

This certificate must be completed and signed by the applicant’s current or past Clinical
Director to confirm the applicant’s current or past clinical commitment to Intensive Care
Medicine in the NHS. If you are the Clinical Director, please ask your senior manager to
complete this form.

The document can either be completed electronically with an electronic signature or signed in hard
copy and scanned into a PDF for submission electronically.


                  I (Clinical Director) Dr A Rhodes

                   of (work address) St George’s Hospital
                                        Blackshaw Road
                                        London
                                        SW17 0QT




     verify that (name of applicant) Dr A T Dewhurst

 (a) was either (i) a substantive, honorary or former NHS or Defence Medical Services
     consultant with sessional or other contracted clinical commitment to Intensive Care
     Medicine on 1 January 2010 or (ii) a substantive SAS (Staff and Associate Specialist) or
     other doctor in the NHS with sessional or other contracted clinical commitment to
     Intensive Care Medicine on 1 January 2010; and

 (b) that he/she undertakes the current sessional or other contracted clinical commitment
     to Intensive Care Medicine described in Part A or the previous employment relevant to
     Intensive Care Medicine (e.g. former NHS consultant) described in Part A.

Signature:                                                              Date:


Details of Clinical Director in case further information is required:

Email address(es):
 andyr@sgul.ac.uk

Telephone number(s):
 07771817787




                                                                                               Page 4 (of 4)

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laparoscopy

  • 1. Foundation Fellowship Application Form V1.0 FOUNDATION FELLOWSHIP APPLICATION FORM This application form is ONLY for use by medical practitioners holding a substantive or honorary NHS or Defence Medical Services consultant post in the United Kingdom with sessional or other contracted clinical commitment to Intensive Care Medicine applying for Foundation Fellowship of the Faculty of Intensive Care Medicine. This also includes consultants who have now retired but held this post on 1 January 2010. The application form must be submitted in both hard copy and electronically. Please complete in full using the electronic version of the document. Do not alter the format. Submit the electronic copy to ficm@rcoa.ac.uk. Large applications should be electronically zipped before sending. The submission will be acknowledged by return email. Submit the hard copy to ‘Foundation Applications, The Faculty of Intensive Care Medicine, Churchill House, 35 Red Lion Square, London WC1R 4SG’. Please read the guidelines in this form carefully and note the supporting documentation required for your application to be considered. Part 1 Contact and reference details 1.1 Title 1.2 First name(s) 1.3 Last name Dr Alexander Timothy Dewhurst 1.4 Address and postcode 1.5 Telephone number (Home) 123 Kyverdale Road 02088062657 London N16 6PS 1.6 Telephone number (Work) 07956475523 1.7 Gender 1.8 Date of birth 1.9 Email address Male 25/01/1964 adewhurst@nhs.net 1.10 College number 1.11 Mobile number 319603 07956475523 1.12 Specialty 1.13 GMC number Anaesthesia 3925148 Page 1 (of 4)
  • 2. Foundation Fellowship Application Form V1.0 Part 2 Qualifications 2.1 Primary Medical Qualification 2.2 University you qualified from MBBS London, Royal Free Hospital School of Medicine 2.2 Main Medical Qualification (please select from list below)  FRCA (Royal College of Anaesthetists)  MRCP (Royal College of Physicians of Edinburgh)  MRCP (Royal College of Physicians of London)  MRCP (Royal College of Physicians and Surgeons of Glasgow)  MRCS (Royal College of Physicians and Surgeons of Glasgow)  MRCS (Royal College of Surgeons of Edinburgh)  MRCS (Royal College of Surgeons of England)  FCEM (College of Emergency Medicine) 2.3 If you have further affiliate Colleges in addition to the College you received your Main Medical Qualification from, please note below Part 3 Application information 3.1 Details of your honorary or substantive 3.2 Number of sessions or other contracted consultant post in the United Kingdom clinical commitment per week devoted including your full work address to Intensive Care Medicine Consultant Anaesthetist with Specialist 2 sessions per week Interest in Cardiothoracic Anaesthesia and Intensive Care St George’s Hospital Blackshaw Road London SW17 0QT 3.3 Please list any additional qualifications (e.g. Diploma, BSc etc.) Diploma in Economics Open University 3.4 Are you in good standing (i.e. are you up to date on your subscriptions) with your College?  Yes  No For Fellows and Members of the Royal College of Anaesthetists only: 3.5 Are you willing to pay the subscription to the Faculty of Intensive Care Medicine via your existing direct debit to the College?  Yes  No Page 2 (of 4)
  • 3. Foundation Fellowship Application Form V1.0 Part 4 Applicant’s Declaration I wish to have my application for the Foundation Fellowship of the Faculty of Intensive Care Medicine considered by the Board of the Faculty of Intensive Care Medicine. I enclose the following documentation:  Completed and signed application form  Completed Clinical Director Certificate (Appendix A) I agree that the Board of the Faculty of Intensive Care Medicine may seek any further information that it considers is relevant to my application, and that my personal details may be made available to a third party(ies), as required, for the purposes of considering my application. I understand that before an assessment of my application can proceed, the Clinical Director Certificate must have been received by the Board. I confirm that, to the best of my knowledge, all of the information that I have provided in this application represents a true and accurate statement. I understand that any serious misrepresentation or false information supplied with the intention to mislead is a probity issue that may be reported to the GMC. I agree that the information provided by me may be processed, in accordance with the Data Protection Act, for legitimate purposes connected with my application. 4.1 Name of applicant 4.2 Signature of applicant* A Dewhurst Signed by: Alexander Dewhurst Date & Time: 15 Feb 2011 12:41:29 PM 4.3 Date declaration signed 11/2/2011 * Signature of applicant: Please either include an electronic signature or print this page out, sign it in hard copy and scan it for submission electronically. Page 3 (of 4)
  • 4. Foundation Fellowship Application Form V1.0 Appendix A CLINICAL DIRECTOR CERTIFICATE This certificate must be completed and signed by the applicant’s current or past Clinical Director to confirm the applicant’s current or past clinical commitment to Intensive Care Medicine in the NHS. If you are the Clinical Director, please ask your senior manager to complete this form. The document can either be completed electronically with an electronic signature or signed in hard copy and scanned into a PDF for submission electronically. I (Clinical Director) Dr A Rhodes of (work address) St George’s Hospital Blackshaw Road London SW17 0QT verify that (name of applicant) Dr A T Dewhurst (a) was either (i) a substantive, honorary or former NHS or Defence Medical Services consultant with sessional or other contracted clinical commitment to Intensive Care Medicine on 1 January 2010 or (ii) a substantive SAS (Staff and Associate Specialist) or other doctor in the NHS with sessional or other contracted clinical commitment to Intensive Care Medicine on 1 January 2010; and (b) that he/she undertakes the current sessional or other contracted clinical commitment to Intensive Care Medicine described in Part A or the previous employment relevant to Intensive Care Medicine (e.g. former NHS consultant) described in Part A. Signature: Date: Details of Clinical Director in case further information is required: Email address(es): andyr@sgul.ac.uk Telephone number(s): 07771817787 Page 4 (of 4)