Clinical Scientist Guided Training Scheme application form

Consent for storing submitted data *

Yes, I give permission to store and process my data

First name *

Surname *

Date of birth *

Gender *

Male

Female

IPEM membership number

Home address *

Home address post code *

Home/Mobile number

Home email

Work department *

Workplace name *

i.e. Hospital or company name

Work address *

Work address post code *

Work telephone number *

Work email *

Employer *

i.e. Trust/Company name

Job title *

Date appointed *

i.e. date appointed to higher trainee / Route 2 post

Enrolment month *

May

November

If this is undecided, add the approximate date

Subject area *

Work Band/Grade *

Proposed assessment pathway *

ACS

AHCS

Do you require reasonable adjustments to your training? *

Yes

Preferred correspondence address *

Home

Work

First degree university *

First degree *

First degree subject *

First degree award level *

First degree award year *

Higher degree university *

Higher degree *

Higher degree subject *

Higher degree award level *

Higher degree award year *

Doctorate university

Doctorate

Doctorate subject

Doctorate award level

Doctorate award year

Additional information

(Thesis titles, project reports, publications & relevant previous training)

Head of department first name *

Head of department surname *

Head of department email *

Supervisor first name *

Supervisor surname *

Supervisor email *

Supervisor HCPC number *

Supervisors must have been registered with the HCPC for a minimum of three years.

Date Supervisor first registered with HCPC *

Upload a copy of your current CV *

Upload a copy of your training plan *

Your structured training plan muct cover the whole of your training period.

Upload a copy of your current job description *

Upload a copy of your IELTS certificate (if required)

Upload a copy of your UK ENIC certificate (if required)

Upload a copy of IPEM's Terms and Conditions document *

This form must have your physical signature (this can be a scanned signature)

Select payment option *

One payment - PO attached

Three annual payments by employer - PO attached

One payment - BACS / CC from trainee

Three annual payments - Scheduled BACS / CC payments from trainee

I wish to apply for enrolment with IPEM onto the IPEM Clinical Scientist Guided Training Scheme and confirm that the information within this application is accurate and true. *

I have discussed this application with my Head of Department and Supervisor and they give their support. Confirmation has been received that appropriate facilities will be made available by the department to offer advanced training in the applicant's specialist subject area and other relevant topics and to participate in the IPEM Scheme for Continuing Professional Development. *

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