Course Application Form

PLEASE APPLY THROUGH THE GENERAL COURSES PAGE

Please note, submitting an application does not guarantee you a place on this course.

Many of our faculty development courses are heavily subscribed so please give as much detail as possible on this form to assist us with shortlisting. Places will be allocated taking into account applicants’ education roles and responsibilities and according to the criteria detailed on the course information page.

We aim to shortlist and contact you at least 8 weeks before the start of the course.

We are required to keep records of certain elements of your data and any training that you undertake with us to meet our statutory obligation to the GMC. For more information, please visit Privacy.

If you would like further information, please email: meded@southampton.ac.uk

Course Details

Title:

Course start date:

Personal Details

Title:

First Name:

Last Name:

Email address:

GMC Number (if applicable):

LAK Number (if applicable):

NMC Number (if applicable):

University Staff ID (if applicable):

External Staff User ID (if applicable):

If you don’t have an Internal or External University User Account, please apply for a Faculty of Medicine External User account here: https://www.nhs.soton.ac.uk/. This will give you access to University training, research materials and other resources.

General information

Main place of work:

Trust:

Position or Job title:

Specialty or subject area:

Primary teaching or education role with University of Southampton BM students:

If other, please state:

Please list any additional teaching or education roles here:

In total approximately how many hours/sessions do you teach BM students annually:

How many years’ experience do you have teaching undergraduate students at the University of Southampton:

Please tell us why you are applying for this course:

Any other comments:

If you are human, do not fill this out