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MB ChB Nominee Form

Congratulations on your nomination for honorary association with the University of Warwick. To complete the nomination process please complete the form below. The personal data provided is required to create a record in our HR systems. We also ask you to indicate your areas of expertise or research interests to allow us to connect you with academic educators at WMS.

Details of the criteria and types of honorary associations can be found in the Honorary Associations criteria document with examples of suitable clinical educators who would be invited to apply.

Please note this form is for MB ChB education teams only.

MB ChB Honorary Associations Flowchart and Process


Part 1 Personal Details 

Have you ever been employed by the University of Warwick (required)

Please note that an Honorary Association cannot be made in connection with work that is paid for.

Part 2 Associate Details

Association Title (Please refer to Appendix A for guidance) (required)

Part 3, Employment Status

I hold a UK immigration status which permits me to work in the UK (if 'other' please state immigration/visa status)

Immigration Status (required)
Professional Conduct (required)

Part 4, Conflicts of Interest

Do you have any conflicts of interest to declare in relation to your application for honorary association? (required)

If yes, you will be required to complete the University's FP1a form to declare conflicts of interest upon receiving your honorary association.

You will be given the option to receive an email copy of your submitted information when you press SUBMIT.

Disclaimer 1
Disclaimer 2
Disclaimer 3

Part 5, Diversity, Inclusion and Statutory Monitoring Information

The University is committed to ensuring Warwick is a fully inclusive community, which recruits and retains talented staff from all sectors of society equally. We believe that every individual should be treated fairly with dignity and respect and be part of a working and learning environment that is free from barriers and that we do not inadvertently make decisions or have processes that treat you less favourably on the basis of your age, race, gender or disability.

Information that we collect in this section will be held on our HR systems and may be used by the University to generate anonymised and aggregated statistics. It will never be shared, reported or published in a form that allows individuals to be identified.


What is your sex?
How would you describe your gender identify?
Do you identify as transsexual?
Do you identify as intersex?

Sexual orientation

How would you describe your sexual orientation?


Do you have an impairment, health condition or learning difference that has a substantial or long-term impact on your ability to carry out day-to-day activities?
If yes, what is the nature of your disability? Please tick the appropriate box. If your disability does not fit any of these types, please select the last but one option. If you experience more than one type of impairment, please select the last option.
Ethnicity: How would you describe your ethnicity or ethnic background?

Religious beliefs:

What are your religious beliefs?
Privacy notice

The University of Warwick will process your personal data provided in this online application form for the purposes of administering and considering your application as an honorary associate. The information provided on the application form will also be used to contact you with relevant information in relation to progress of your application and if successful, your honorary appointment. 

The legal basis for processing this personal data is that it is necessary for the performance of services. 

Your application may be shared with your employer, whose approval will be sought for your holding an Honorary Association at Warwick together with your substantive employment.

Your first name and surname, job title, place of work, clinical practice, teaching interest/expertise, research interests will be placed on an internal database.  If you have indicated consent above, WMS may contact you in relation to academic or research interests.  

Your personal data will not be transferred outside of the EEA, will be kept securely by the University of Warwick and will be retained for a period of seven years after the expiry of your honorary association unless your application is unsuccessful, at which point your personal data will be kept for six months from the point your application is unsuccessful.  

The University of Warwick is the Data Controller of any information you have entered on this form and is committed to protecting the rights of individuals in line with Data Protection Legislation. The University's Data Protection webpages provide further information on your rights and how the University processes personal data. If you wish to submit a data subjects rights request, make a complaint or report a suspected personal data breach, please contact the University’s Data Protection Officer by email at

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