application for clinical attachment Your Personal DetailsSpeciality interested in*please choose from list1. Psychiatry2. PaediatricsIf you have chosen psychiatry, please state psychiatry sub speciality Surname* First Names* Title Address (Line 1) Address (Line 2) City Postcode Country Tel. No. (Home)MobileEmail* Do you currently work in the NHS? Yes No If you have a disability, do you require any reasonable adjustments to be made to support you in undertaking the clinical attachment? Yes No Are you a United Kingdom (UK), European Community (EC) or European Economic Area (EEA) National? Yes No Please select the category that relates to your current immigration status. This status will be subject to checking before interview. HSMP/Tier 1 Indefinite Leave to remain/enter Post Graduate Doctors and Dentists Dependant/Spouse visa Clinical attachment visa Student Visitor Working Holiday visa/Tier 5 Youth Mobility Work Permit/Tier 2 Tier 5 Temporary Workers Refugee Please supply details of any visa currently held, including number, start/expiry dates and details of any restrictions.*Visa no. Start date (DD/MM/YY)Start date (DD/MM/YY) Expiry date (DD/MM/YY)Expiry date (DD/MM/YY) Details of Restriction:Details of Restriction: Does your visa have a condition restricting employment or occupation in the UK? Yes No Please supply details below: Supporting InformationIn this section please give your reasons for applying for a clinical attachment with us. Supporting informationDeclarationThe information in this form is true and complete. I agree that any deliberate omission, falsification or misrepresentation in the application form will be grounds for rejecting this application or subsequent dismissal if employed by the organisation. Where applicable, I consent that the organisation can seek clarification regarding professional registration details. I agree to the above declaration* Tick here How did you find out about clinical attachments with us? NHS website Search engine LPT staff College/university Word of mouth ReferencesPlease state the names and contact details of the people who have agreed to supply references covering a minimum of 3 years employment/training. If you are or have been employed, these should include your two most recent employers, your line manager or someone in a position of responsibility who can comment on your work experience, competence, personal qualities and suitability for the post. Please ensure that you provide full contact details. Referee 1Full name* Title Job title Address Post code Country Telephone no. Email address* Relationship* Referee 2Full name* Title Job title Address Post code Country Telephone no. Email address* Relationship* NameThis field is for validation purposes and should be left unchanged.