Academic Gold Medal Application Form

Consent for storing submitted data *

Yes, I give permission to store and process my data

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First Name *

Surname *

Email *

Daytime Phone Number *

Your preferred number, can be a mobile

Current place of work *

Hospital, university, company etc. We do not need the address

Membership number of person applying/being nominated

Please leave blank if you can't find it

Who are you applying for?

Myself

Someone else

Please describe in up to 500 words the substantial and sustained track record at an outstanding level of contribution to the advancement of academic practice. *

List attachments you wish to submit to support this application *

This should include a current CV