This document is an application form for the Foundation Fellowship of the Faculty of Intensive Care Medicine. It requests contact information, qualifications, details of the applicant's clinical commitment to intensive care medicine, and a declaration signed by the applicant and their clinical director. The applicant must currently hold or have previously held a substantive or honorary NHS or Defence Medical Services consultant post in the UK with sessions in intensive care medicine.

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
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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
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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.
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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
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