Essential Skills in Medical Education 
Course Application Form

PAGE 1	
Section 1 – PERSONAL INFORMATION
	
1. Personal Details	

Name: 	
	
Address: 	

GOC number 	
College Membership number (if applicable)	
Contact details

Email address: 	
Telephone	Home:	
Mobile:	
2. General	
Are there any adjustments that may be required to be made should you be invited to a meeting at the College?	
If so, please state here:	
	
Data Protection	

	
If you succeed and are accepted onto the ESME course, the information will be used in the administration of your time on the course and to gather course feedback.
	
3. Declaration	
I declare that the information I have given in this form is accurate and true. I understand that providing misleading or false information will disqualify me from applying to be sponsored through the course OR, if selected, may result in my being asked not to complete the course.

I declare that, if successful, I will be required to provide feedback about the course and my experience on the course. This feedback will be gathered during and at the end of the programme. 

Signature                                                                                                          Date	
Completed forms should then be sent by email to education.ea@college-optometrists.org  or by post to Education EA, The College of Optometrists, 42 Craven Street, London, WC2N 5NG. Forms should be received no later than 5pm on Thursday 14 March 2019. 	

PAGE 2	
Section 2 – APPLICATION FORM

1. Employment history	
Please detail your employment history starting with your most recent role first. Include dates, job title and a two sentence summary of your role.  	

PAGE 3	
APPLICATION FORM (CONTINUED)

2. Experience of teaching or training in optometry	
In a maximum of 500 words please detail below your teaching or other relevant  experience to date including who you have been teaching and in what areas	

	

PAGE 4	
APPLICATION FORM (CONTINUED)

3. Reasons for undertaking the course	
In a maximum of 500 words please explain why you would like to do this course and how you believe it will benefit your career.	

	

PAGE 5	
APPLICATION FORM 

Continuation sheet