Technologist Training Scheme application form

Consent for storing submitted data *

Yes, I give permission to store and process my data

Title *

First name *

Surname *

Date of birth *

IPEM membership number (if applicable)

Home address *

Home post code *

Home phone number

Mobile number

Home email

Employer *

Job title *

Work grade/band *

Date appointed *

Hospital name *

Hospital department *

Work address *

Work post code *

Work email *

Work phone

Induction month *

May

November

Training Co-ordinator name *

(Including title)

Training Co-ordinator hospital *

Training Coordinator email *

Training supervisor 1 name *

Training supervisor 1 email *

Training supervisor 2 name

Training supervisor 2 email

Copies of relevant academic certificates *

Training plan *

The training plan should be a word document or PDF.

List of competencies *

Employer purchase order *

This must be a full Purchase Order document, containing your employer's financial details (a PO number not on an official form cannot be accepted)

Do you require any reasonable adjustments to be implemented during your training or viva as a result of a disability or dyslexia? *

Yes

You may upload a copy of your NHS Heath Passport or other written documentation from your employer

I wish to apply for to join the IPEM Technologist Training Scheme and declare that the information I have given in this application is, to the best of my knowledge, accurate and true. I agree to be governed by the Rules of IPEM, including its Code of Professional Conduct, and accept that any breaches of the Rules or the Code of Professional Conduct will be dealt with under IPEM's Disciplinary Procedure. *

All information collected is treated in strict compliance with the Data Protection Act. You can read our Privacy Policy here.

When enrolled on the training scheme, you will also be awarded IPEM Associate membership at no additional cost. Confirmation of your membership will be provided once your training scheme application has been approved. You are not required to submit a separate membership application.