Application form for completion by potential new examiners

Which role are you applying for? *

College membership number *

Surname *

Forename(s) *

Specialty

Membership grade *

Which examiner panel would you like to serve on? *

Secondary panel (optional)

If one of the following specialties, please indicate your preferred sub-panel.

Genetics

Haematology

Veterinary pathology

Would you like to be involved with any of the following subpanels?

Autopsy (CHAT)

Cervical Cytopathology (CHCCT)

Histopathology Stage A

Chemical Pathology Stage A

Are you prepared to assess submissions of published work, dissertations, and casebooks?

Yes

If yes, please provide details of areas of special interest:

Please complete one of the following statements.

I am active in clinical practice at:

I am active in research at:

Please complete all the relevant statements below.

Are you participating in the College’s CPD scheme?

If you are participating in an alternative CPD scheme, please provide details:

If you are currently participating in an EQA scheme, please provide details:

If you are currently working in a CPA registered or accredited laboratory, please provide details:

If you are actively involved in training and educational supervision, please provide details:

If you have been involved with undergraduate and/or postgraduate medical examinations, please provide details of qualification(s) and role(s):

Terms of application

I declare that:

I will be available to examine at least three times during the five-year term
I will undertake training in the examination process
I am prepared to have my examining practice observed
I am not currently subject to any investigations related to my professional performance or probity

Declaration

I declare all of the above statements to be true.