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Examination Application Form CR1

EXAMINATIONS OFFICE USE ONLY

Examination Fee

Enrolled/Subs Paid

London Course Fee

Acknowledged

EXAMINATIONS OFFICE USE ONLY

Candidate Number

Attempts

Physics Venue

Anatomy Venue

APPLICATION FORM FOR THE

FIRST EXAMINATION FOR THE FELLOWSHIP IN CLINICAL RADIOLOGY

PLEASE READ THE GUIDANCE NOTES OVERLEAF

PLEASE COMPLETE IN BLOCK CAPITALS

I wish to enter the examination at Spring/Summer/Autumn*Year

CR1I wish to attempt the following module(s)

(*please circle choice below)

OFFICEUSE ONLY

EXAMINATIONS OFFICE USE ONLY

Attempt Sitting Result Attempts

I wish to enter PHYSICS YES/NO* PH

I wish to enter ANATOMY YES/NO* AN

I wish to sit PHYSICS in(*please circle choice)

*London/Birmingham/ManchesterDublin/Hong Kong/Singapore

If my first choice venue is not available,I wish to sit PHYSICS in

*London/Birmingham/ManchesterDublin/Hong Kong/Singapore

I wish to sit ANATOMY in(*please circle choice)

*London/Hong Kong/Singapore

Surname (Family Name) Date of Birth Gender

Other (Given) Names (in full)

Correspondence Address

Daytime Telephone Number Facsimile Number E-mail address

Medical Qualifications (eg MB BS) and Dates Obtained Primary Medical School (city and country)

PLEASE DETAIL YOUR CURRENT (OR MOST RECENT) CLINICAL RADIOLOGY TRAINING POST

POST TITLE/GRADE(eg Registrar, Resident)

HOSPITAL/TRAINING PROGRAMMEEXACT DATES (day/month/year)

FROM TO

/ / / /

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PLEASE TICKONEOF THE FOLLOWING STATEMENTS (and complete if appropriate)

I have not attempted the First FRCR Examination (any format or module) before

I last attempted the examination at theSpring/Summer/Autumn/

Winter*

Yearsitting

PLEASE TICKONEOF THE FOLLOWING STATEMENTS (and complete if appropriate)

I am registered with the GMC and my registration number is

I am not registered with the GMC and enclose a copy of the personal details page of my passport

Candidate's DeclarationI confirm that the information given on this form is complete and correct

Candidate's Signature Date

CANDIDATES WHO HAVE UNDERTAKEN THEIR CLINICAL RADIOLOGY TRAINING IN THE UK MUST OBTAIN THE

SIGNATURE OF THEIR TRAINING PROGRAMME DIRECTOR AT EACH ATTEMPT

Training Programme Director's DeclarationI confirm that the number of modules being entered by the candidate named overleaf is appropriate.

Training Programme Director's Signature Training Programme Director's Name Date

This form, once completed, should be returned to:The Examinations Office (CR1)

The Royal College of Radiologists, 38 Portland Place, London, W1B 1JQ

Please see the Examination Calendar for details of the Examination Fee and Application Closing DateThe completed form must be accompanied by the Examination Fee

and all other requested documentation

GUIDANCE NOTES

(1) If you are registered with the General Medical Council (GMC), you must give your names in full EXACTLY asthey appear on the Medical Register.

(2) If you are not registered with the GMC, you must give your names in full EXACTLY as they appear on yourpassport and must enclose a copy of the personal details page of your passport with this form. You mustbring your passport with you when you sit the examination.

(3) You must use EXACTLY the same format of name each time you attempt any part of the FRCRExaminations. If your name changes on the GMC Medical Register or your passport you must provideacceptable formal confirmation of the alteration.

(4) Please also refer to the document "Guidance Notes for Examination Candidates: Completion of ApplicationForms" for further guidance about the application process.

(5) If you are undertaking specialty training in the UK, you must have enrolled with the Royal College ofRadiologists as a trainee and be up-to-date with your annual subscription in order to enter the examination.If you are unsure about your status, please contact the College's Training Office for guidance and

clarification.