Trainee Details: Name: Primary Email Address: RCPI Identification Number: Training Programme Details: Type of Training Programme BST/HST: – Specialty: Future Planned Placement: Hospital: (where known, please detail hospital and from From: and to date) To: Expected Completion date: Job Share: Reason for application: Intended Start Date for Job Share Post: Signature: Applicants Signature: Date: For office use only: National Specialty Director/Associate Director for BST GIM Approval: Title: Signature: Date:
Trainee Details: Name: Primary Email Address: RCPI Identification Number: Training Programme Details: Type of Training Programme – BST/HST: Specialty: Future Planned Placement: (where known, please detail hospital and from and to date) Hospital: From: To: Expected Completion date: Job Share: Reason for application: Intended Start Date for Job Share Post: Signature: Applicants Signature: Date: For office use only: National Specialty Director/Associate Director for BST GIM Approval: Title: Signature: Date:
Job-Share-request-form.docx