ACCEA

ADVISORY COMMITTEE on

CLINICAL EXCELLENCE AWARDS

		

		

APPLICATION FORM FOR MEMBERSHIP OF THE REGIONAL SUB-COMMITTEES OF THE ADVISORY COMMITTEE ON CLINICAL EXCELLENCE AWARDS 2016 AWARDS ROUND

I wish to apply for membership of the 

                                                                     Regional Sub-Committee
          (insert name of committee -  see note 1) 

As: Chair/ Medical Vice Chair / Professional Member / Employer Member / Lay Member*

(*Delete as applicable (see note 2))

Part 1 – Personal Information

Please complete all of the information requested below.   The address you give      is the one that will be used to send application forms

Full name (including title)
	
Full address 
(for correspondence)

	
Telephone number (including code)	
Mobile number	
E-Mail address	
Fax number	

Occupation (see note 3)

Academic qualifications

Current level of Clinical Excellence Award or Distinction Award and year awarded (only applicable for professional applicants; see note 4)

Part 2 - Additional information

In the box below please say why you want to be a member of the Regional Sub-Committee and briefly explain what you are able to offer as a member.  Please highlight any relevant skills and experience that you have obtained through your employment, voluntary or community activity and any relevant education and training.  Please include here if you have received valuing diversity training within the last 18 months.

	

Part 3 - Declaration of interests (see note 5)

Please give details of any business or personal interests that might be relevant to the work of ACCEA and which could lead to a real or perceived conflict of interests.

	

Part 4 - Referees 

Please give the names and contact details of two referees.     

Name

Address

Email	
Name

Address

Email	

Please indicate by ticking the box that you agree to ACCEA contacting the referees if necessary           

Please indicate where you saw the advertisement for sub-committee membership or how you became aware of the opportunity? 

Part 5 - Declaration

I confirm that to the best of my knowledge and belief, the information given in this form is complete and correct

Signature

	
 Date

 	

A concise CV (no more than two sides of A4) and monitoring form should be sent with your application form by email to:

ACCEA.Secretariat@dh.gsi.gov.uk

ACCEA Secretariat
Room 6th Floor North Side
Wellington House
133-155 Waterloo Road
LONDON SE1 8UG