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Get UK GMC GEN1 2015-2024

Section 1 applicant s details Applicant s name Applicant s GMC reference number Period of employment From D M Y To Position held by applicant Please give a brief description of duties. GEN1 Employer s reference This form is to be completed by a Human Resources representative or the applicant s line manager. It should not be completed by the applicant. Please note that a copy of the completed reference will be shared with the applicant. If you are a non-medical employer please complete sections 2 and 4. If you are a medical employer please complete all sections. Section 2 to be completed by all employers Are you aware of any issues that would call into question this doctor s character conduct or fitness to practise For example were they subject to any disciplinary proceedings whilst employed by you If yes please provide details. yes no Question 3a Was the applicant working in a medical capacity Please note that clinical attachments and observer posts are not considered to be medical practice. If yes please answer question 3b. If no go to section 4. regulator If yes please give us the name of the relevant medical regulator. Please provide the name of the authority that regulates doctors in the country or region the doctors was working in for example General Medical Council UK. Do not provide the name of an individual person* If no please explain why the applicant was allowed to work in a medical capacity without holding registration or a licence with the appropriate medical regulator. Section 4 - declaration Your name Your position Email address This should be an official work email address not a webmail address such as yahoo hotmail or googlemail* Telephone number Last updated on 08 April 2015. Please make sure you are using the most up-to-date version of the form* W www. gmc-uk. org T 0161 923 6602 44 161 923 6602 when calling from outside the UK Page 2 of 3 Your signature Date Name and address of organisation Official stamp. GEN1 Employer s reference This form is to be completed by a Human Resources representative or the applicant s line manager. It should not be completed by the applicant. Please note that a copy of the completed reference will be shared with the applicant. If you are a non-medical employer please complete sections 2 and 4. If you are a medical employer please complete all sections. Section 2 to be completed by all employers Are you aware of any issues that would call into question this doctor s character conduct or fitness to practise For example were they subject to any disciplinary proceedings whilst employed by you If yes please provide details. Section 2 to be completed by all employers Are you aware of any issues that would call into question this doctor s character conduct or fitness to practise For example were they subject to any disciplinary proceedings whilst employed by you If yes please provide details. yes no Question 3a Was the applicant working in a medical capacity Please note that clinical attachments and observer posts are not considered to be medical practice. .

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