GP Mentoring in Nepal Application Form

First Name(s)*

Surname*

Date of Birth*

DD

MM

YYYY

Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

How did you find out about PHASE:*

Email*

Enter Email Confirm Email

Phone Number*

GMC Registration Number

If GMC Number not applicable, please explain why:

Please Upload your CV*

(if no CV, please list your medical qualifications and employment history in a word document).

Skills and Experience*

Briefly outline the relevant skills and experience that you have. Please include and voluntary work undertaken.

Personal Statement*

In this section, please include your reasons for wanting to volunteer for PHASE, your hobbies and your interests, personal qualities and any other information relevant to your application.

About your Visit*

Please specify if you have any particular time constraints and whether there are any areas or circumstances in which you would not be able to work.

Medical Conditions

Please list here any pre-existing medical conditions or allergies and whether you are taking medication regularly. This will not usually cause any problems but it will be helpful so that we can advise you of any additional restrictions or precautions.

Reference*

Please list the name, organisation, address and email of at least one referee who PHASE may contact. The person should be able to vouch for your professional abilities and character.

Other

If you have any other questions or comments you may write them here.

Consent

Please tick this box to confirm that you are happy for us to contact you using the details provided. We will use your contact details to contact you about your application to join the programme and to share information about our work, news from Nepal, any any events, fundraising and appeals we are running. We will never sell or trade your details. You can unsubscribe at any time by emailing info@phaseworldwide.org or by clicking the unsubscribe link in any email we send.