Nomination Form


    Your proposer and seconder are asked to email independently to confirm their support of this nomination

    Candidate Details

    Please limit your responses to the following questions to 150 words in total (e.g. 75 words each). These responses will not be edited.

    Probity Declaration

    By submitting this nomination, I declare that I have not, in the UK or outside:

    • Been convicted of a criminal offence (including any spent convictions) or have proceedings pending against me.
    • Had any cases adversely considered by the GMC, other professional regulatory body, or other licensing body or have any such cases pending against me.
    • Had any disciplinary actions taken against me by an employer or contractor or have had any contract terminated or suspended on grounds relating to my fitness to practice

    I agree to the above declaration