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WMS Nominee Information Form
WMS Nominee Information Form
Please complete and submit the form below if you wish to be considered for an Honorary Association. Part 3 should be completed only, if you wish to be considered for an association as an Honorary Associate Clinical Professor.
Is your application a:
Renewal of existing Association
Academic Clinical Fellow New Application
Academic Foundation Year Doctor New Application
Part 1 Personal Details:
Date of Birth:
/GDC/HCPC/NMC Registration Number (if not applicable, enter N/A):
Preferred email address:
Link to your professional website (e.g. your personal page on a university website, linked-in page etc. Not Facebook or informal social page):
Current substantive post (this is your main job and it is external to
Current substantive employer (the organisation paying your salary):
Are you employed by the
, name and contact details of your Clinical Line Manager or Clinical Director, with whom you have discussed your application:
, name and contact details of your Trust Medical Director or equivalent:
Have you ever been employed by the University of Warwick
I currently have an employment contract with the University of Warwick
I used to have an employment contract with the University of Warwick
I have never been employed by the University of Warwick
If you answered ‘Yes’, to ‘currently employed’ or ‘have been employed in the past’ give brief details:
Please note that an Honorary Association cannot be made in connection with work that is paid for.
Please select one of the following
I currently receive payment for work undertaken on behalf of
I used to receive payment for work undertaken on behalf of
I have never received payment for work undertaken on behalf of
If you answered ‘Yes’ to ‘currently receive payment’ or ‘used to receive payment’ please give brief details
Name of your proposer at Warwick Medical School (This must be an academic employee of
Please upload your: a. Head and shoulders photo for use on the Medical School website. b. Recent Curriculum Vitae
No files are currently attached.
a. I have uploaded my photo.
b. I have uploaded my CV.
Part 2 Interests
Describe your interests under at least one of sections 1, 2 and 3. If you are applying for a renewal, please indicate briefly what you have done in the course of your previous association with
, as well as your proposed activities for a future term. Please do not exceed 150 words per section.
1. Area of clinical practice (if relevant):
2. Area of teaching interest/expertise (if relevant):
2a. Teaching qualifications achieved (eg, Fellowship of the Higher Education Academy,
, completed modules; such as Essentials of Medical Education) (if relevant)
2b. Teaching-related training courses undertaken (dates and duration), (if relevant):
3. Area of research interest (if relevant):
4. Any pre-exisiting relationships with Warwick Medical School:
5. Please provide up to 10 key words or phrases that describe your
interests (each word or phrase to be comma separated). These words should reflect the areas in which you would be positioned to contribute to research or provide student support and should be as specific as possible e.g. functional gastrointestinal disorders, assessment in medical education, placement of dental implants.
Part 3 Applicants for the title “Honorary Associate Clinical Professor”
ONLY COMPLETE THIS SECTION IF YOU WISH TO APPLY FOR THE TITLE OF HONORARY ASSOCIATE CLINICAL PROFESSOR
Criteria for Honorary Associate Clinical Professor
To undertake a role in curriculum design and development and / or to make a significant contribution to research complementary to the research programme of Warwick Medical School.
For Honorary Clinical appointments: To work to academic objectives that will be agreed annually as part of a joint
/ University appraisal using Follett principles.
I am applying for the title of Honorary Associate Clinical Professor.
If No, proceed to section 4
If Yes, I confirm I will work with my proposer to list measurable academic outcomes for the period, with timescales. I understand that these should be added to my personal development plan to be assessed at my annual joint clinical appraisal.
Part 4 Conflicts of Interest
Do you have any conflicts of interest to declare in relation to your proposer or the potential honorary role?
If ‘Yes’. I wish to declare the following potential or actual conflicts of interest:
You will be required to complete the University’s
to declare conflicts of interest if the honorary association goes ahead.
You will be given the option to receive an email copy of your submitted information when you press ’submit’.
On some occasions we may request details of three referees. We will contact you if this is the case.
Please answer all questions
I am aware that an Honorary Association, if awarded, is unpaid and does not constitute a contract of employment
(If employed) I have discussed this Honorary Association with my substantive employer who is supportive
I agree to participate in laboratory induction and occupational health checks if requested to do so
I agree to comply with all relevant research governance processes
(for all healthcare professionals) I hold professional registration and appropriate insurance, and I agree to inform
if I cease to hold professional registration or appropriate insurance
I agree that the information provided in Part 2 of the form, including my photograph, can be used by
on its website and in promotional material
indicates a required field
By submitting your application you are consenting to the University of Warwick using and processing your personal data for the purposes of processing your application details and subsequently for all purposes anticipated under the application or subsequent honorary appointment.