Anyone who meets any of the categories below will not be automatically disqualified, but they may be asked to step down from membership of a NICE committee, at the sole discretion of NICE. Please tick the box for any of the following that apply to you and provide further information on the circumstances: subject of a bankruptcy restrictions order or interim order have been dismissed (except by redundancy) by any NHS or social care body have had an earlier term of appointment terminated under a disqualification order under the Company Directors Disqualification Act 1986 have been removed from trusteeship of a charity Please provide further information: …………………………………………........................................ ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… Any committee members or chairs who are appointed because of their up to date professional health and care service knowledge and experience and work in a regulated profession should have an active registration with the appropriate professional body when they are appointed and when their appointment is renewed. For medical committee members or chairs, this includes a licence to practise. I accept the above conditions for committee membership and confirm that none of the disqualifications listed in points 1a-c above apply, and any items listed in point 2 have been declared. Name:…………………………………………………………… Signature:………………………………………………………. Referees
Anyone who meets any of the categories below will not be automatically disqualified, but they may be asked to step down from membership of a NICE committee, at the sole discretion of NICE. Please tick the box for any of the following that apply to you and provide further information on the circumstances: subject of a bankruptcy restrictions order or interim order have been dismissed (except by redundancy) by any NHS or social care body have had an earlier term of appointment terminated under a disqualification order under the Company Directors Disqualification Act 1986 have been removed from trusteeship of a charity Please provide further information: …………………………………………........................................ ………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………… Any committee members or chairs who are appointed because of their up to date professional health and care service knowledge and experience and work in a regulated profession should have an active registration with the appropriate professional body when they are appointed and when their appointment is renewed. For medical committee members or chairs, this includes a licence to practise. I accept the above conditions for committee membership and confirm that none of the disqualifications listed in points 1a-c above apply, and any items listed in point 2 have been declared. Name:…………………………………………………………… Signature:………………………………………………………. Referees
applicant-info-professional-member.docx