A-Team Application Form
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Upon completion, please erase all information in RED. PERSONAL DETAILS: First name: Last name: Specialty: Age: Gender: Date of Birth: Citizenship: Marital status: Profession of spouse: Reason for applying to work abroad: Available From (Month, Year): Phone number E-mail address Address Skype ID LANGUAGE SKILLS: MAKE SURE THAT YOU MENTION THE LEVEL OF YOUR ENGLISH SKILLS. If you have passed the A- Team language screening, you should write Advanced. Language Level MEDICAL AUTHORITY REGISTRATIONS: MAKE SURE THAT YOU MENTION THE NAME OF THE MEDICAL AUTHORITY AND INCLUDE THE COUNTRY (E.G., GENERAL MEDICAL COUNCIL, UK)
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Transcript of A-Team Application Form
Upon completion, please erase all information in RED.
PERSONAL DETAILS:
First name:Last name:Specialty:Age:Gender:Date of Birth:Citizenship:Marital status:Profession of spouse:Reason for applying to work abroad:Available From (Month, Year):Phone numberE-mail addressAddressSkype ID
LANGUAGE SKILLS:MAKE SURE THAT YOU MENTION THE LEVEL OF YOUR ENGLISH SKILLS. If you have passed the A-Team language screening, you should write Advanced.
Language Level
MEDICAL AUTHORITY REGISTRATIONS:MAKE SURE THAT YOU MENTION THE NAME OF THE MEDICAL AUTHORITY AND INCLUDE THE COUNTRY (E.G., GENERAL MEDICAL COUNCIL, UK)
Medical Authority Registration Number
EDUCATION AND POST GRADUATE EXAMS PASSED:
MAKE SURE THAT YOU INCLUDE YOUR PRIMARY MEDICAL QUALIFICATION AND SPECIALISATIONS, AS WELL AS ANY ADDITIONAL DEGREES YOU MAY HAVE COMPLETED.
From (Month, Year)
To (Month, Year)
Name and Location of University
Subject or Specialty
Level of course
COURSES COMPLETED:IN THIS SECTION, PLEASE INCLUDE ANY LIFE SUPPORT COURSES OR WORK-RELATED CERTIFICATES YOU MAY HAVE RECEIVED.
Name of course Date completed
CURRENT EMPLOYMENT:
From: Month, Year
To: Month, Year
Hospital Country Position title
HOSPITAL/CURRENT EMPLOYMENT DESCRIPTIONIN THIS SECTION, PLEASE MENTION THE DEPARTMENTS THAT YOUR CURRENT HOSPITAL OR INSTITUTION HAS. MENTION THE NUMBER OF BEDS AND ANY OUTPATIENT OR AMBULATORY SERVICES OFFERED.
Specialties
No. of hospital beds
Outpatient services offered:
Name and address of the hospital:
PLEASE DESCRIBE IN DETAIL YOUR DAILY ROUTINE, MENTIONING THE SKILLS YOU USE AND THE PATIENTS YOU SEE. PLEASE ALSO DESCRIBE THE PROCEDURES YOU MIGHT CARRY OUT, AS WELL AS THE NUMBER OF PATIENTS YOU ARE IN CONTACT WITH ON A DAY-TO-DAY BASIS.
MENTION IF YOU TAKE PART IN ANY ON-CALL SHIFTS AND THE FREQUENCY OF THEM. ALSO MENTION IF YOU TAKE PART IN THE DAILY WARD ROUNDS OR IF YOU PROCESS ANY PATIENTS’ PAPERWORK (E.G., DISCHARGE PAPERS, REFFERALS).
PREVIOUS EMPLOYMENT:
From: Month, Year
To: Month, Year
Hospital: Country: Position title:
HOSPITAL/PREVIOUS EMPLOYMENT DESCRIPTIONIN THIS SECTION, PLEASE MENTION THE DEPARTMENTS THAT YOUR CURRENT HOSPITAL OR INSTITUTION HAS. MENTION THE NUMBER OF BEDS AND ANY OUTPATIENT OR AMBULATORY SERVICES OFFERED.
Specialties:
No. of hospital beds:
Outpatient services offered:
Name and address of the hospital:
PLEASE DESCRIBE IN DETAIL YOUR DAILY ROUTINE, MENTIONING THE SKILLS YOU USE AND THE PATIENTS YOU SEE. PLEASE ALSO DESCRIBE THE PROCEDURES YOU MIGHT CARRY OUT, AND THE NUMBER OF PATIENTS YOU ARE IN CONTACT WITH ON A DAY-TO-DAY BASIS.
MENTION IF YOU TAKE PART IN ANY ON-CALL SHIFTS AND THE FREQUENCY OF THESE. ALSO MENTION IF YOU TAKE PART IN THE DAILY WARD ROUNDS OR IF YOU PROCESS ANY PATIENTS’ PAPERWORK (E.G., DISCHARGE PAPERS, REFFERALS).
PREVIOUS EMPLOYMENT:
From: Month, Year
To: Month, Year
Hospital: Country: Position title:
HOSPITAL/PREVIOUS EMPLOYMENT DESCRIPTIONIN THIS SECTION, PLEASE MENTION THE DEPARTMENTS THAT YOUR CURRENT HOSPITAL OR INSTITUTION HAS. MENTION THE NUMBER OF BEDS AND ANY OUTPATIENT OR AMBULATORY SERVICES OFFERED.
Specialties:
No. of hospital beds:
Outpatient services offered:
Name and address of the hospital:
PLEASE DESCRIBE IN DETAIL YOUR DAILY ROUTINE, MENTIONING THE SKILLS YOU USE AND THE PATIENTS YOU SEE. PLEASE ALSO DESCRIBE THE PROCEDURES YOU MIGHT CARRY OUT, AND THE NUMBER OF PATIENTS YOU ARE IN CONTACT WITH ON A DAY-TO-DAY BASIS.
MENTION IF YOU TAKE PART IN ANY ON-CALL SHIFTS AND THE FREQUENCY OF THESE. ALSO MENTION IF YOU TAKE PART IN THE DAILY WARD ROUNDS OR IF YOU PROCESS ANY PATIENTS’ PAPERWORK (E.G., DISCHARGE PAPERS, REFFERALS).
SUMMARY OF EXPERIENCE- BY DEPARTMENT
MANY PEOPLE SPEND TIME IN OTHER DEPARTMENTS AS PART OF SPECIALTY TRAINING, CHANGES IN CAREER PATH, AMBULANCE WORK, VOLUNTARY WORK, ETC. PLEASE LIST THE VARIOUS DEPARTMENTS YOU HAVE WORKED IN AND WHEN THIS WORK OCCURRED.
FOR EXAMPLE: Surgery, SHO, 12/2009-01/2011.
Department Position held. From: (Month,Year)
To: (Month,Year)
SUMMARY OF EXPERIENCE- BY SKILL
PLEASE LIST ALL SKILLS YOU HAVE EXPERIENCE IN, INCLUDING THINGS LIKE VENEPENCTURE, ECG SKILLS, SURGICAL SKILLS AND TREATMENTS ADMINISTERED.
Skill Number of procedures undertaken:
From: (Month, Year)
To: (Month, Year)
RESEARCH AND PUBLICATIONS:
Author/s Title Date
TEACHING RESPONSIBILITIES:
Specialty/area of responsibility From: (Month, Year)
To: (Month, Year)
REFERENCES:
Name: Hospital: Contact phone number:
Email address:
