APPLICATION FORM SPECIALTY TRAINING ST3

RCSI DEVELOPING HEALTHCARE LEADERS WHO MAKE A DIFFERENCE WORLDWIDE

	

APPLICATION FOR SPECIALIST TRAINING  
COMMENCING JULY 2020

Closing Date: Thursday 5th December 2019

Read the enclosed guidelines carefully prior to completing the application form

This application must be submitted unbound and unstapled but in the correct order as per page numbers 

Please tick which Specialty you are applying for:	
Cardiothoracic Surgery		
 General Surgery		
 General & Emergency Surgery*		
Otolaryngology		
Vascular Surgery		
Plastic Surgery		
 Trauma and Orthopaedic		
Urology		
Neurosurgery		
Oral & maxillofacial Surgery		
Paediatric Surgery		
     *New Programme – see information document on mSurgery

•	There is no fee applicable to this application
•	Interviews will take place week commencing Monday 23rd March 2020
•	Please ensure you read the attached Progression document for ST2 – ST3 
•	You are not required to submit transcripts as these will be on file from CST1 application
•	Any attempt to provide misleading or false information to improve your score will result in automatic disqualification.
•	Successful applicants appointed to the Programme must commence their Specialty post in July 2020 No deferrals of commencement of programme in July 2020 permitted.
•	All information contained in this document is deemed to be a record held by RCSI for the purposes of processing your application to Specialty Training. RCSI is committed to protecting your privacy in line with applicable data protection legislation including the ‘EU General Data Protection Regulation and policies RCSI has in place under that legislation. RCSI will hold scanned copies of all applications for 1 year following the closing date. No originals are held or returned unless specifically requested by the applicant.
•	Submit applications unbound & unstapled – no plastic pockets or folders please.

Note: Documents, with the exception of items under “Research and Academic”, will not be accepted after the closing date. There will be a provision for applicants to submit items such as thesis, publications, presentations etc. which will be awarded after the closing date up to 5pm Friday 17th January 2020. Under NO circumstances will marks be given beyond this date based on accepted/ awarded thesis, publications or presentations.
Validated Logbooks and Trainee Assessment Reports for final six months of Clinical experience will be accepted up to 5pm Friday 17th January 2020. 

Personal Details

	
Full name	''Click here and type''	
Irish Medical Council number	''Click here and type''	
IMC Registration type	''Click here and type''	
Nationality	''Click here and type''	
Date of birth	''DD / MM / YY''	
Email	''Click here and type''	
Phone	''Click here and type''	
Mobile	''Click here and type''	
Postal address	''Click here and type''	

Education 
	
Medical School	''Click here and type''	
Dates (from –to)	''DD / MM / YY'' to ''DD / MM / YY''	
Type of degree	''Click here and type''	
Place in final Mb, BCh. BOA (centile)
	''Click here and type''	
Undergraduate Achievements 	''Click here and type''	
First Class honours degree 	''Click here and type''	
Second Class honours degree 	''Click here and type''	

Postgraduate Achievements 
	
Membership Awarded Please Submit Verification  which includes your Part B marks as this will be required for progression metrics

Qualification	Date Passed	College	Office Use	
Part A	''DD / MM / YY''	''Click here and type''		
Part B	''DD / MM / YY''	''Click here and type''		

Qualifications	Date 
from: 	Date 
to: 	College	Office Use	
''Click here and type''	''DD / MM / YY''	''DD / MM / YY''	''Click here and type''		
''Click here and type''	''DD / MM / YY''	''DD / MM / YY''	''Click here and type''		
''Click here and type''	''DD / MM / YY''	''DD / MM / YY''	''Click here and type''		
''Click here and type''	''DD / MM / YY''	''DD / MM / YY''	''Click here and type''		
Please Specify Any Other Relevant Degree(s) You Have Obtained 

Please Specify Any Other Relevant Diploma(s) You Have Obtained

Qualifications 	Date 
from: 	Date 
to: 	College	Office Use	
''Click here and type''	''DD / MM / YY''	''DD / MM / YY''	''Click here and type''		
''Click here and type''	''DD / MM / YY''	''DD / MM / YY''	''Click here and type''		
''Click here and type''	''DD / MM / YY''	''DD / MM / YY''	''Click here and type''		
''Click here and type''	''DD / MM / YY''	''DD / MM / YY''	''Click here and type''		
Note: Verification of other relevant degrees / diplomas must be provided in English. 

Research /Academic Development 	
Publications  Please provide Verification
List only full length peer reviewed papers in scientific journals.  Do not list abstracts or case reports.  Do not list papers which have been submitted but not yet accepted.  The title, reference and list of authors must be exactly as in the published journal.	

Name of Journal  	Impact Factor	Title of Paper	Reference	PIMD Number	Author status 1st, 2nd etc.	Office Use	
''Click here and type''	''Click here and type''	''Click here and type''	''Click here and type''	''Click here and type''	''Click here and type''		
''Click here and type''	''Click here and type''	''Click here and type''	''Click here and type''	''Click here and type''	''Click here and type''		
''Click here and type''	''Click here and type''	''Click here and type''	''Click here and type''	''Click here and type''	''Click here and type''		
''Click here and type''	''Click here and type''	''Click here and type''	''Click here and type''	''Click here and type''	''Click here and type''		
''Click here and type''	''Click here and type''	''Click here and type''	''Click here and type''	''Click here and type''	''Click here and type''		
''Click here and type''	''Click here and type''	''Click here and type''	''Click here and type''	''Click here and type''	''Click here and type''		
''Click here and type''	''Click here and type''	''Click here and type''	''Click here and type''	''Click here and type''	''Click here and type''		
Published Case Reports Please provide Verification
	List only published case reports in which you are the first author.

Title
	Journal	Reference	PIMD Number	Author status 1st - ONLY	Office Use	
''Click here and type''	''Click here and type''	''Click here and type''	''Click here and type''	''Click here and type''		
''Click here and type''	''Click here and type''	''Click here and type''	''Click here and type''	''Click here and type''		
''Click here and type''	''Click here and type''	''Click here and type''	''Click here and type''	''Click here and type''		
''Click here and type''	''Click here and type''	''Click here and type''	''Click here and type''	''Click here and type''		
''Click here and type''	''Click here and type''	''Click here and type''	''Click here and type''	''Click here and type''		
''Click here and type''	''Click here and type''	''Click here and type''	''Click here and type''	''Click here and type''		
''Click here and type''	''Click here and type''	''Click here and type''	''Click here and type''	''Click here and type''		

Presentation  Please provide Verification
List only Oral Presentations which you personally presented or poster presentation in which you were First Author.  List only presentations / posters at recognised Surgical or Scientific Meetings / Conferences.  Do not list presentations / posters in which you were a co-author.
	
Name of Meeting
	
Date	
Venue	
Title of Presentation	
Office Use	
''Click here and type''	''DD / MM / YY''	''Click here and type''	''Click here and type''		
''Click here and type''	''DD / MM / YY''	''Click here and type''	''Click here and type''		
''Click here and type''	''DD / MM / YY''	''Click here and type''	''Click here and type''		
''Click here and type''	''DD / MM / YY''	''Click here and type''	''Click here and type''		
''Click here and type''	''DD / MM / YY''	''Click here and type''	''Click here and type''		
''Click here and type''	''DD / MM / YY''	''Click here and type''	''Click here and type''		
''Click here and type''	''DD / MM / YY''	''Click here and type''	''Click here and type''		

Research in Progress
You must submit a letter of verification from your Research Supervisor in Relation to this Research (NB Letters will not be Accepted from SpRs)	
''Click here and type''

	

Professional Development 	

Professional and Technical skills course Please provide Verification

you have completed (courses should be of direct relevance to the specialty you are applying for ( do not list mandatory RCSI education courses) 

Course	Date /Duration	Venue	Office Use	
''Click here and type''	''DD / MM / YY''	''Click here and type''		
''Click here and type''	''DD / MM / YY''	''Click here and type''		
''Click here and type''	''DD / MM / YY''	''Click here and type''		
''Click here and type''	''DD / MM / YY''	''Click here and type''		
''Click here and type''	''DD / MM / YY''	''Click here and type''		
''Click here and type''	''DD / MM / YY''	''Click here and type''		

Audit projects Please provide Verification

Please list the Audit Projects you have Completed.  You should include the Title, the Standard used, a brief Summary of the First Cycle results, the Intervention and a brief Summary of the Second Cycle results.

''Click here and type''	

Additional Information Please provide Verification

List any additional information that may be relevant from commencement of your internship to now e.g. Prizes Received, Teaching Activities etc. 

''Click here and type''

	

Previous Appointments:  
Intern posts, Core Surgical Training Posts – in date order, starting with most recent 

Hospital	Specialty	Start Date	End Date	
''Click here and type''	''Click here and type''	''DD / MM / YY''	''DD / MM / YY''	
''Click here and type''	''Click here and type''	''DD / MM / YY''	''DD / MM / YY''	
''Click here and type''	''Click here and type''	''DD / MM / YY''	''DD / MM / YY''	
''Click here and type''	''Click here and type''	''DD / MM / YY''	''DD / MM / YY''	
''Click here and type''	''Click here and type''	''DD / MM / YY''	''DD / MM / YY''	
''Click here and type''	''Click here and type''	''DD / MM / YY''	''DD / MM / YY''	

Applicant’s Signature:	

I declare that to the best of my knowledge and belief that all the particulars furnished in connection with this application are true and accurate.  I understand that I may be required to submit documentary evidence in support of any particulars given by me on my Application Form.  I understand that any false or misleading information submitted by me may render any offer of a training position and associated employment offers as null and void.
	
Signature:	Date:	

For office use only

Specialty assigned		
Documents checked and verified		
Confirmation of acceptance received		
Signed off by:		

Please submit one signed unstapled copy of this form along with any supporting documentation to:

ST3 Applications
National Surgical Training Centre
Royal College of Surgeons in Ireland
121 St Stephens Green
Dublin 2

Email: janecunningham@rcsi.ie 

Closing date for receipt of applications is 5pm Thursday 5th December 2019