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Personal Details

Name:                                           

Sex:                                               

Address:                                       

E-mail:                                        

Telephone:                                   Home-

                                                      Mobile-

Date of birth:                      

Marital Status:                             

Nationality:                                   

G.M.C. Registration number:    

National Training Number:       

Date of CCT completion:            

Medical Qualifications

MRCPCH

Part II (clinical)                      Oct. 20XX (first attempt)          R.C.P.C.H

Part II (written)                      Nov. 20XX (first attempt)         R.C.P.C.H     

Part-I                                      Jan. 20XX (first attempt)           R.C.P.C.H.

M.B.B.S                                  Sept. 19XX                           

Other Qualifications

APLS (provider):                         Balamory Hospital, Nov. 20XX

           (provider):                         Royal Infirmary; Oct. 20XX

NLS   (Selected as instructor):      Australian Hospital, Jan 20XX

          (provider):                          South Hospital; Aug. 20XX

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