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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.

Part 1 Personal Details:

If ‘yes’, name and contact details of your Clinical Line Manager or Clinical Director, with whom you have discussed your application:
If :‘yes’, name and contact details of your Trust Medical Director or equivalent:

Please note that an Honorary Association cannot be made in connection with work that is paid for.
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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 WMS, as well as your proposed activities for a future term. Please do not exceed 150 words per section.

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 NHS / University appraisal using Follett principles.

If No, proceed to section 4

Part 4 Conflicts of Interest
You will be required to complete the University’s FP1a form
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.
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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.
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