Signature Name Date PART 3: To be completed by applicant Applicant Declaration I confirm that: - I have attached all required supporting documentation. the information contained within my application and the supporting documentation is correct and truthful. I understand that this information will be treated confidentially but give my permission for all the information in this application to be considered by the panel and passed to the receiving foundation school. I give my permission for information in this application to be used in anonymised form for review and evaluation of the process and outcomes of foundation training. I hereby formally apply for consideration for pre-allocation to the foundation school I have indicated. Signature Name Date Email address For queries Required Supporting Documents A report, by the current medical specialist treating your condition or Occupational Health physician, in which they will be required to: - describe the current medical condition or disability describe the nature of the ongoing treatment and frequency explain why the follow up must be delivered in a specific location rather than by treatment centres in the UK Submitting your application form Please mark your envelope: -
Signature Name Date PART 3: To be completed by applicant Applicant Declaration I confirm that: - I have attached all required supporting documentation. the information contained within my application and the supporting documentation is correct and truthful. I understand that this information will be treated confidentially but give my permission for all the information in this application to be considered by the panel and passed to the receiving foundation school. I give my permission for information in this application to be used in anonymised form for review and evaluation of the process and outcomes of foundation training. I hereby formally apply for consideration for pre-allocation to the foundation school I have indicated. Signature Name Date Email address For queries Required Supporting Documents A report, by the current medical specialist treating your condition or Occupational Health physician, in which they will be required to: - describe the current medical condition or disability describe the nature of the ongoing treatment and frequency explain why the follow up must be delivered in a specific location rather than by treatment centres in the UK Submitting your application form Please mark your envelope: -