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Template Form EEA Evidence of Two Years Postgraduate Experience Form DC0018 PDF 32481716

Doctor X has completed a minimum of 2 years full time postgraduate experience in medicine and surgery between start and finish dates at a public hospital. Their supervising consultant confirms the details of rotations in surgery and medicine including start and finish dates and number of weeks. The consultant verifies the information as accurate, signs and dates the form with their official position, contact details and hospital stamp.

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523 views2 pages

Template Form EEA Evidence of Two Years Postgraduate Experience Form DC0018 PDF 32481716

Doctor X has completed a minimum of 2 years full time postgraduate experience in medicine and surgery between start and finish dates at a public hospital. Their supervising consultant confirms the details of rotations in surgery and medicine including start and finish dates and number of weeks. The consultant verifies the information as accurate, signs and dates the form with their official position, contact details and hospital stamp.

Uploaded by

Nasro
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Evidence of postgraduate

experience form
To be completed by the applicant’s supervising consultant. Please complete BOTH pages.
THIS FORM MUST NOT BE COMPLETED BY THE APPLICANT.
Section A

I confirm that
Doctor’s name

Doctor’s GMC reference number

has gained a minimum of 2 years continuous full time post qualification experience at a public hospital in at
least one branch of medicine and one branch of surgery between:

Start date D D M M Y Y Y Y Finish date D D M M Y Y Y Y

Please complete the table below providing details of the applicant’s postgraduate experience

Rotation Surgery or Start date Finish date Number of


Medicine (please weeks
tick)

Surgery 
Example: Obstetrics
0 1 0 1 2 0 0 8 3 0 0 3 2 0 0 8 13 weeks
& Gynaecology
Medicine 

Surgery 
D D M M Y Y Y Y D D M M Y Y Y Y
Medicine 

Surgery 
D D M M Y Y Y Y D D M M Y Y Y Y
Medicine 

Surgery 
D D M M Y Y Y Y D D M M Y Y Y Y
Medicine 

Surgery 
D D M M Y Y Y Y D D M M Y Y Y Y
Medicine 

To be completed the applicant’s supervising consultant. Please complete BOTH pages. THIS
FORM MUST NOT BE COMPLETED BY THE APPLICANT.
Section B
I confirm that the information I have given is true and accurate to the best of my knowledge and that I am
not a spouse, family member, or someone with whom the applicant has a close personal, business or financial
interest.

Full name of
supervising
consultant or
medical director

Address of hospital

Telephone number This should be an official work telephone and fax number, not a
Fax number personal home telephone number.

Email This should be an official work email address not a webmail address such as Yahoo, Hotmail or Googlemail.

Signature Date

Name

Position held

Official stamp (Note that we cannot accept this form as evidence without an official stamp)

This form was last updated on 16 November 2015

Please make sure that you are using the most up-to-date version of the form.
Telephone us on 0161 923 6602 (or +44 161 923 6602 if calling from outside the UK) Page 2 of 2

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