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WMS Nominee Form

Privacy Statement : We will only use the information on this form to process your application for an honorary association

Please complete and submit the form below if you wish to be considered for an Honorary Association. Part 3 should be completely only, if you wish to be considrered 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.
Attach file
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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 Applicants for the title “Honorary Professor”
 

 
ONLY COMPLETE THIS SECTION IF YOU WISH TO APPLY FOR THE TITLE OF HONORARY PROFESSOR

Criteria for Honorary Professor
Experience at a level equivalent to that of a professor
Expected to make a significant contribution to the development of WMS
Meeting at least one of the following requirements:
- An international reputation for outstanding research and teaching in a specialist field
- Evidence of academic leadership, knowledge development and innovation in research and teaching
- An eminent professional practitioner or recognised authority in a specialist field who will provide strategic input into WMS and as an advocate for the University.

If Yes, please be aware that you should already have made informal contact with the Dean of WMS and provided an indicative CV. References may be required; if so you will be asked to provide the names of up to 3 referees who must have given explicit consent for you to share their personal data with the University of Warwick. Your application will be reviewed by the Honorary and Visiting Professor Appointments Panel at WMS before a recommendation is made. The panel meets termly.

If No, proceed to section 5

Part 5 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.
Disclaimers

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 personal data will not be shared or disclosed to any third parties external to the University of Warwick with the exclusion of your first name and surname, professional links, job title, place of work, clinical practice, teaching interest/expertise, research interests and key words which will be placed on the University webpage. The legal basis for placing this personal data on the website is that it is necessary for the performance of services.


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 this information and is committed to protecting the rights of individuals in line with Data Protection Legislation. Please visit the Information Commissioner’s Office’s webpages for further information in relation to your rights and the University’s Data Protection webpages for further information about how the University processes your personal data. The University’s Data Protection Officer, A Bajaj, can be contacted through infocompliance@warwick.ac.uk”>infocompliance@warwick.ac.uk and any requests or complaints should be made in writing to the University’s Data Protection Officer.


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Privacy statement
We will only use the information on this form to process your application for an honorary association.
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