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[Application form - Part 1] Personal information

1 Contact information

Surname/Family name Ekpe

First name ModupeOluwa

Middle name(s) Foluke

Preferred name

Any other name(s) used, where different from the above

Title Dr

Date of birth 15/02/1976

Country of birth Nigeria

Do you have a National Insurance Number? No

Address line 1 3 Asuoha Kingsley Street

Address line 2 Agbama Housing Estate

City/town Umuahia

Post code 440221

Country Nigeria

Home telephone +2348033839205

Mobile telephone +2348033839205

Work telephone +2348033839205

May we contact you at work? Yes

Please indicate your preferred telephone number Mobile

Email address dupedeclan@gmail.com

Please note: Most recruitment communications will be via Oriel message direct to your Oriel account. Any communications will also be
sent by email so you must provide an active email address. Please ensure you check your Oriel account regularly for messages throughout
the recruitment process.

Your contact details can be updated within the "My Profile" section of your portal.

To update your profile, click on the pencil icon alongside the fields.

2 Right to work in the UK

Your nationality - country pertaining to nationality Nigeria

Are you a United Kingdom (UK)/Irish national? No

Are you a European Union (EU) national, European Economic No

Area (EEA) national or Swiss national?

Your current immigration status (personal status)

3

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Your eligibility to be considered for this position will be determined by your immigration status on the closing date for
applications for this post. You must inform the recruitment office if your immigration status changes at any point in the
recruitment process. If your immigration status changes after an offer of a training programme has been made, this could affect
your right to work.

Please select your current personal immigration status from the No current immigration status in the UK
following options. If you are a dependant of a main visa holder,
please select the main visa category from the following options.
You will then be asked whether you are a dependant on this visa
status. You may be asked for more information once you have
selected a status. If your visa status is not listed, you should
contact the relevant recruitment office.

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[Application form - Part 1] Equality and diversity information

4 Equality and diversity information

The information you enter on this Equality and Diversity monitoring form will be used for monitoring purposes only and will not be used in assessing
and/or scoring your application or at interview stage. This information is kept confidential and accessibility is strictly limited to individuals on a relevant
basis.

5 Monitoring information

Most public sector employers including healthcare organisations are required to collect data about an applicant. The information is used
solely for monitoring purposes to ensure that recruitment policies and procedures are applied fairly and do not discriminate against
individuals. We believe that it is good practice to employ a diverse workforce that reflects the communities we serve.

The information you share with us will be used to monitor and evaluate how well we are doing in eliminating discrimination and advancing
equality. The NHS is committed to the principles of fairness, consistency, meritocracy and equality of opportunity. The Equality Act 2010
requires equal treatment in access to employment as well as private and public services, regardless of age, disability including long-term
health conditions, gender re-assignment, marriage or civil partnership, maternity or pregnancy, race, religion or belief, sex and sexual
orientation.

Date of birth 15/02/1976

Gender Female (including trans woman)

I would describe my ethnic origin as: Black or Black British - African

Please select the option which best describes your sexuality Heterosexual or Straight

Do you live and work permanently in a gender other than that No

assigned at birth?

Please indicate your religion or belief: Christian

Are your day to day activities limited because of a health problem No

or disability which has lasted, or is expected to last at least 12
months? (please include problems related to old age)

Please indicate your marital status Married/Civil Partner

Are you pregnant, on maternity leave or returning from maternity No

leave?

6 FOR APPLICANTS APPLYING TO NORTHERN IRELAND POSTS ONLY

To demonstrate our commitment to equality of opportunity in employment we need to monitor the community background of applicants and
employees, as required by the Fair Employment and Treatment (NI) Order 1998. We therefore ask you to indicate your community
background by selecting the appropriate option below. Please note that it is an offence under the Fair Employment and Treatment (NI)
Order 1998 to give false information to the Trust.

Please select your community background

Please indicate your marital status

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[Application form - Part 1] Employment history

7 Full employment history (UK/Overseas)

I have no employment history

Where experience is required for a post, ticking this box will make you ineligible.

If your posts are concurrent, please ensure you list each post separately stating the exact whole time equivalent for each, ensuring posts are listed in
chronological order including exact start and finish dates. For consecutive posts, please ensure the end date of a post is not also the start date of the
next.

8 Employment history - data entry section

IMPORTANT NOTE: Please use this data entry section to add/update your employment history and ensure you use the action buttons
('Add ', ’Edit’, 'Cancel ' etc) to submit information against your record.

Important information
Please list all medical/dental employment from current/most recent employment history detailing back to graduation from medical/dental
school. For rotational posts in Core Training programmes, please list each component post separately. Please also list posts that you are
due to undertake but have not yet started, that is, future posts.

If you are currently in employment and do not have an "end date" please put the end date as being the day before the commencement
date for the post for which you are applying (as per the Applicant Guide). If you leave your current post before this date you must send
details to the relevant Deanery/NHS England recruitment office.

Important information regarding employment gaps

The system will autogenerate any gaps in employment of longer than four weeks within three years preceding the advertised post
commencing from date. Please note the following would be considered an employment gap:

•any expected or planned career gap between submission of the application form and the post commencing from date of the advertised
post
•any potential gaps between the end date of your last planned post and the advertised post commencing from date where you do not
currently know what your employment status will be - you should provide information about your intentions for this period
•any periods of short-term, ad hoc or locum work greater than four weeks; where this is the case, please summarise the nature and
amount of full time equivalent experience gained across any posts undertaken during this period
•any gaps where you have stepped out of programme with the expectation of returning such as to undertake research in a formal post or
to take a career break
•periods of leave such as maternity leave or career breaks
•where you have less than 3 years employment history

If you have less than 3 years employment history, you must note the dates and explanation of what you were doing before your
first employment post as a gap (for example Undergraduate Education).

Duration of post
Employer name Post title Post type Please specify Start date End date (in months)

Federal Medical Specialty training

Resident Doctor 05/10/2022 29/08/2025 34.8
Center Umuahia (ST)

Abia State Hospital

Management Dental Officer Non-training post 04/07/2011 30/09/2022 134.9
Board

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University of Port
Harcourt Teaching Dental Officer Non-training post 02/03/2009 31/12/2010 22.0
Hospital (UPTH)

Abia State Hospital

Management
Dental Officer Non-training post 14/03/2005 31/03/2006 12.6
Board, Dental
Centre

University College Dental Career

House Officer 05/04/2004 11/03/2005 11.2
Hospital, Ibadan Development Post

9 Employment gaps

Do you have any gaps in your employment of more than 4 weeks No

duration?

Please include career breaks for maternity leave, health etc

The answer to this question has been auto-generated based on

the employment history entered above. Therefore this appears as
a read-only field, you are not required to answer it. If you think that
this is incorrect, please review the employment records entered
previously.

Do you have any gaps in your employment history, of more than 4 No

weeks duration, prior to three years before the advertised
programme start date for this post?

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[Application form - Part 2] Agreements

1 Agreements

This training post/programme is not normally available to any dentist/individual who has previously relinquished or been released/removed
from a training programme.

Have you previously relinquished or been released or removed No

from a training programme in any specialty?

Do you currently hold a National Training Number (NTN) or No

Deanery Reference Number (DRN) in the specialty to which you
are applying and are you applying to continue your training in
another area/region?
The information you enter on this part of the application form will be passed direct to the recruiting department at the area/region or national recruiting
organisation. It will not be used in assessing and scoring your application. If you are successful the details entered in this part of the application form
will then be passed to your prospective employer and/or HR department.

Please note that incomplete application forms will not be considered.

I confirm that I understand the implications if I do not complete this Yes

application form correctly.

I have read the guidance for this specialty/application and Yes

understand the specialty entry requirements for the training
programme I have chosen. See Dental applicant guidance.

Level to which you are applying Dental Core Training Year 1 (DCT1)

2 Personal details

Do you currently hold a National Training Number (NTN)? No

Are you a member of the Protecting Vulnerable Groups (PVG) No

Scheme?

Please note, this will only apply to applicants who have previously
worked in Scotland.

Do you have a disability, learning difficulty or health condition, or No

are pregnant or breastfeeding and require any specific
arrangements / adjustments to enable you to undertake a
computer based test, interview or assessment, or other selection
process? Depending on the circumstance/request, you may be
asked to provide medical evidence.

Further information can be found here.

If you have a disability, defined as a physical or mental impairment No

which has a substantial and long term effect on your ability to carry
out normal day to day activities and you meet the minimum criteria
as specified in the Person Specification, do you wish to be offered
an interview under the *Disability Confident Scheme?

Are you considering an application for less than full-time training No

(LTFT)?
Please note that selecting 'Yes' does not result in an application for
LTFT training. This must be submitted directly to the region/area
appointed to

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3 Entry qualification

Please give details of your primary dental qualification

Qualification Bachelor of Dental Surgery (BDS or BChD or BDentS)

Date of qualification 23/02/2004

Dental school/university Other: please specify

Please enter dental school/university University of Ibadan, Nigeria

Dental school/university address line 1 Agbowo, Ibadan, Oyo State, Nigeria

Dental school/university address line 2

City/town Ibadan

Postcode 200221

Country of primary dental education Nigeria

Language skills
4 Evidence of English language proficiency

As a doctor, dentist or other healthcare professional, you are required to demonstrate skills in written and spoken English which allow you
to perform your clinical skills safely and to communicate effectively on medical and/or health topics with patients, colleagues and the public.

Was your undergraduate training taught in English? Yes

5 Special circumstances

Do you have special circumstances that may require you to remain No

in a geographical area for specific caring or health reasons?

For information about the Special Circumstances that can be

considered please see the guidance and eligibility criteria on our
website.

6 Programme specific information

Do you wish to apply for a deferred start date?3 No

7 Academic clinical fellowship / clinical specialty training

Have you also applied for academic clinical fellowship (ACF) No

training in this specialty in the 2025 academic recruitment round?

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Have you also applied for a Clinical Lectureship post for which you No
require clinical benchmarking?

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[Application form - Part 2] References

8 References information

Reference reports are not used at eligibility checking or at the selection centre but will be requested and reviewed after offers have been
made and prior to confirmation of appointment for successful applicants. The reference process is designed to check the accuracy of your
previous employment and training history and to provide assurance of your suitability for employment.

You must provide contact details, including e-mail addresses, of three referees who have supervised your clinical training during the last
two years of your employment or undergraduate training. One referee must be your current or most recent consultant or educational
supervisor familiar with your clinical development.

NHS pre employment checks require your NHS Employer to take up references spanning the last three years of your work and
education. You may be required to provide further referee details to your NHS employer, if appointed.

If you are applying for an Academic Clinical Fellowship post, one of your referees must be able to provide the academic reference.

You should contact your clinical referees in advance to confirm that they are willing to provide a reference and are available and able to do so in the
time period required for selection and appointment.

Please ensure they provide you with their preferred email address. This will be the email address that will be used when requesting references.

Your future employer may need to request an employment reference from your dental school if you graduated less than three years ago. This
information will not be requested until after you have been made a conditional offer of employment.

Employment or training post 1

9
Referee 1

This referee must be your present or most recent employer, Consultant or Educational Supervisor.

Post specialty Restorative Dentistry

Post Grade Specialty Training ST1

Start date 05/10/2022

End date 29/08/2025

Referee title Dr

Referee forename Chimezie

Referee surname Okoronkwo

Job title of referee Principal Dental Officer

What was their role in relation to you (e.g. Consultant, manager)? Supervisor

Contact email address okoronkwochimezie2015@gmail.com

Please ensure you enter a valid email address as your referee

may be asked to submit an online reference in support of your
application.

Confirm referee email address okoronkwochimezie2015@gmail.com

GDC/GMC registration no:

Contact phone number +2348055620460

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Employment or training post 2

10
Referee 2

Post specialty Dental Career Development

Post Grade Senior Dental Officer

Start date 04/07/2011

End date 30/09/2022

Referee title Dr

Referee forename Ogbonna

Referee surname Ohondu

Job title of referee Principal Dental Officer

What was their role in relation to you (e.g. Consultant, manager)? Supervisor

Contact email address g.ohondu349@gmail.com

Please ensure you enter a valid email address as your referee

may be asked to submit an online reference in support of your
application.

Confirm referee email address g.ohondu349@gmail.com

GDC/GMC registration no:

Contact phone number +2347038661349

Employment or training post 3

11
Referee 3

Post specialty Restorative Dentistry

Post Grade Specialty Training ST1

Start date 05/10/2022

End date 29/08/2025

Referee title Dr

Referee forename Chimaroke

Referee surname Onyejekwe

Job title of referee Principal Dental Officer

What was their role in relation to you (e.g. Consultant, manager)? Supervisor

Contact email address dr.chimarokeonyejekwe@gmail.com

Please ensure you enter a valid email address as your referee

may be asked to submit an online reference in support of your
application.

Confirm referee email address dr.chimarokeonyejekwe@gmail.com

GDC/GMC registration no:

Contact phone number +2348038801323

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[Application form - Part 2] Fitness to practise

12 Data Protection Act 2018

The Data Protection Act 2018 requires us to provide you with certain information and to obtain your consent before processing sensitive
data about you. Processing includes: obtaining, recording, holding, disclosing, destruction and retaining information. Sensitive personal
data includes any of the following information: criminal offences, criminal convictions, criminal proceedings, disposal or sentence.

The information that you provide in this Declaration Form will be processed in accordance with the Data Protection Act 2018. It will be
used for the purpose of determining your application for this position. It will also be used for purposes of enquiries in relation to the
prevention and detection of fraud in the interest of patient safety.

This Declaration Form and any information provided relating to a positive declaration will be kept securely and in confidence, and access to it will be
restricted to designated persons within the recruiting organisation and other persons who need to see it as part of the selection process and who are
authorised to do so. If successfully appointed to a training post, this information may be passed to designated persons in your first or lead employing
organisation and any organisations through which you rotate.

13 Fitness to practise

It is vitally important that you read, understand and answer the questions asked in this section by ticking each box. Please read
the notes below carefully before completing this part of the form. If you require further information, please contact the recruiting
organisation that you are applying to. All enquiries will be treated in strict confidence.

We aim to promote equality of opportunity and are committed to treating all applicants for positions fairly and on merit regardless of race,
gender, marital status, religion, disability, sexual orientation or age. We undertake not to discriminate unfairly against applicants on the
basis of criminal conviction or other information declared.

The position you have applied for has been identified as a regulated activity within the terms of the Safeguarding Vulnerable Groups Act
(2006), as amended by the Protection of Freedoms Act (2012) and is eligible for an enhanced criminal records check (Access NI in
Northern Ireland, Protecting Vulnerable Groups Scheme (PVG) in Scotland) under the provisions of the Police Act 1997 (Criminal
Records) Regulations (as amended). The enhanced criminal record check will, where appropriate to the role, also include any information
which may be held against the barred lists for working with children and / or adults.

Before you can be considered for appointment in a position of trust as a trainee in this position we need to be satisfied about your
character and suitability.

The position you have applied for is exempt from the Rehabilitation of Offenders Act 1974. This means that you must declare all criminal
convictions, including those that would otherwise be considered ‘spent’, under this Act, unless they are considered protected.

Answering ‘yes’ to any of the questions below will not necessarily bar you from an appointment. This will depend on the nature of the
position for which you are applying and the particular circumstances.

Prior to making a final decision concerning your application, we shall discuss with you any information declared by you that we believe may
have a bearing on your suitability for the position. If we do not raise this information with you, this is because we do not believe that it
should be taken into account. You still remain free, should you wish to discuss the matter with the interviewing panel. As part of assessing
your application, we will only take into account relevant criminal record and other information declared.

Please answer the following questions. If you answer "YES" to any of the questions, you will need to complete the FTP declaration form
found in the resource bank. Please submit this form via e-mail to the lead recruiter (details can be found on the recruitment leads page).
Please mark the email "CONFIDENTIAL". Emails should be received by no later than the submission deadline for applications.

If you would like to discuss what effect any previous convictions, police investigations or fitness to practise proceedings taken or being

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taken either in the UK or by an overseas licensing or regulatory body might have on your application, you may contact the fitness to
practise contact (details can be found on the recruitment leads page).

Where you have a Fitness to Practise declaration as a result of a health issue, please contact the recruitment lead for a confidential
discussion to determine the level of detail that you need to provide.

If FTP issues occur after your application has been submitted you should inform the recruitment office if the recruitment process is ongoing
or your appointing region if offers have already been made.

1. Are you currently bound over, or do you have any convictions or No

cautions (including warnings and reprimands) which are not
deemed 'protected' under the amendment to the Exceptions Order
1975, issued by a Court or Court-Martial in the United Kingdom or
in any other country? N.B. You do not need to tell us about parking
offences or fixed penalty notices but other driving offences must be
declared.

2. Have you been charged with any offence in the United Kingdom No
or in any other country that has not yet been disposed of?
Please note:
You are reminded that you have a continuing responsibility to declare any new criminal convictions, police investigations or fitness to
practise proceedings that arise after application submission.

Where recruitment is ongoing, you should inform the recruitment office. After an offer has been made, you should notify the appointing
region. Once in a training post or programme, you should inform your employer(s) and the Postgraduate Dean.

You do not need to tell us about parking offences or fixed penalty notices but other driving offences must be declared.

3. Are you aware of any current NHS Counter Fraud and Security No
Management Service (CFSMS) investigation following allegations
made against you?

4. Have you been investigated by the Police, NHS CFSMS or any No

other Investigatory Body resulting in a current conviction or
dismissal from your employment or volunteering position?

Investigatory bodies include: Local Authorities, Customs and Excise, Immigration, Passport Agency, Inland Revenue, Department of Business,
Innovation and Skills, Department of Work and Pensions, Security Agencies, Financial Service Authority, or any successor bodies to the above. Note:
This list is not exhaustive and you must declare any investigation conducted by an Investigatory Body.

5. Have you ever been dismissed by reason of misconduct from No

any employment, volunteering, office or other position previously
held by you?

6. Have you ever been disqualified from the practice of a No

profession or required to practice subject to specified limitations /
conditions / warnings following fitness to practise proceedings by a
regulatory or licensing body in the United Kingdom or in any other
country?

7. Are you currently the subject of any investigation or fitness to No

practise proceeding by any licensing or regulatory body in the
United Kingdom or any other country?

8. Are you subject to any other prohibition, limitation, or restriction No

that means we are unable to consider you for any position for
which you are applying?

9. Do you know of any other matters in your background which

might cause your reliability or suitability for employment to be

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called into question? No

If you have answered "YES" to any of the questions, you will need to complete the FTP declaration form found in the resource bank. Please submit
this form via e-mail to the lead recruiter (details can be found on the recruitment leads page). Please mark the email "CONFIDENTIAL". Emails should
be received by no later than the submission deadline for applications.

A list of FTP email addresses is available in the Applicant Handbook found in the Resource Bank. They can also be found on
the Recruitment Leads page on Oriel for each Recruitment Office.

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[Application form - Part 2] Competencies

14 Professional registration

Are you registered with the UK General Dental Council (GDC) as a No

dentist?

If you are not currently registered with the GDC as a dentist, I am currently a registered member of the Medical and Dental
please explain why you think you will be eligible to gain UK GDC Council of Nigeria and have over 10 years of experience as a
registration as a dentist by the time of appointment 1 (e.g. final dental practioner in my country.
year dental student)

1Time of appointment is the start date of the post/programme to

which you are applying

Other professional registration(s)

Do you have any other professional registrations? No

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[Application form - Part 2] Declarations

15 Confirmation

I have met/or am expecting to meet the essential entry criteria as Yes

set out in the person specification for the specialty and entry level
to which I am applying, including, where necessary the acquisition
of the relevant competencies and college memberships.

I confirm that my data may be used anonymously for research and Yes
evaluation purposes in particular for the continued development of
national application processes and shared with the GDC/GMC and
Royal Colleges for this purpose.

16 Declarations

Important: The Data Protection Act 2018 requires us to advise you that we will be processing your personal data. Processing
includes: holding, obtaining, recording, using, sharing and deleting information. The Data Protection Act 2018 defines 'sensitive
personal data' as racial or ethnic origin, political opinions, religious or other beliefs, trade union membership, physical or mental
health, sexual life, criminal offences, criminal convictions, criminal proceedings, disposal or sentence.

The information that you provide in this Application Form will be processed in accordance with the Data Protection Act 2018. It
will be used for the purpose of determining your application for this position. It will also be used for purposes of enquiries in
relation to the prevention and detection of fraud.

Once a decision has been made concerning your appointment, the recruiting organisation will not retain this declaration for any longer than
is necessary. This declaration will be kept securely and in confidence. Access to this information will be restricted to designated persons
within the trust / employing organisation who are authorised to view it as a necessary part of their work.

Declaration 1: I declare that the information I have given in support of my application, including information supplied on this form and any attached
appendices, is, to the best of my knowledge and belief true and complete. I understand that if it is subsequently discovered that any statement is false
or misleading, or that I have withheld relevant information, particularly on criminal convictions and/or fitness to practise and/or have breached the
Standards for the Dental Team stipulated by the General Dental Council/General Medical Council/any other licensing or regulatory body of which I am
a member, my application may be disqualified. If I have already been appointed, I understand that I may be dismissed and I may be reported to the
General Dental Council/General Medical Council/any other licensing/regulatory body of which I am a member.

Declaration 2: I declare that my answers to the questions on this form, any attached appendices and any other application forms required by
Deaneries/NHS England recruitment offices are my own work and are not copied or reproduced from any other sources. I understand that if any of my
answers are discovered not to be original, my application may be disqualified.

Declaration 3: I understand that if I am allocated to a training opportunity, any subsequent contract of employment will be subject to satisfactory pre-
employment checks and subject to a condition that the information provided on the application form or any related documents is correct. I also
understand that pre-employment checks will be carried out to review and confirm the details of my application.

Declaration 4: I understand that employment offered in this training programme is subject to satisfactory medical clearance which may include a
medical examination and/or blood tests.

Declaration 5: I understand that if recommended for training I will be subject to a Disclosure and Barring Service (DBS) check (previously known as
CRB) or the Protecting Vulnerable Groups Scheme (PVG) in Scotland. I am aware that I must inform the Deaneries/NHS England recruitment offices
of any new criminal convictions, police investigations or fitness to practise proceedings that arise after the completion of this application form.

Declaration 6: I confirm that if there is a change in my training status once I have submitted my application (i.e. removal of training number,
interdeanery transfer etc), which would significantly affect the content of my application form, I will inform the Lead Recruiter for the training
programme. Failure to disclose such changes could lead to the withdrawal of any training offer.

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Declaration 7: I have read and understand the Privacy Notice and understand that my Personal and Sensitive Personal Data will be processed in the
manner set out in this Notice

Declaration 8: I have read in full and confirm the acceptance of the Dental recruitment applicant declaration.

I agree to the above declarations Yes

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[Supporting information] Evidence

1 POSTGRADUATE EXPERIENCE

Will you have at least 12 months whole time equivalence (WTE) Yes
postgraduate clinical experience to the scope of a dentist by the
start date of the post?

2 DENTAL CORE TRAINING

Will you have completed a UK Dental Core Training Year 1 No

programme or equivalent by the start date of the post?

3 PROFESSIONAL REGISTRATION

Will you be eligible for full UK GDC registration by the start date of No
the post?

PLEASE NOTE: If you are applying for temporary registration

please select 'NO'

Will you be eligible for temporary UK GDC registration by the start Yes
date of the post?
Based on your answer above it is important that you rank your preferences appropriately, i.e. as you have stated you will be eligible for temporary UK
GDC registration (not full), you MUST move all of the preferences labelled
'NOT suitable for temporary GDC registrants' to the ‘not wanted’ column so you are not considered for these posts.

For more information on how to obtain temporary registration please follow the link: Temporary Registration

If you receive an offer you are not eligible for, the DCTNRO reserve the right to withdraw this offer of training.

Please check this box to confirm that you understand and accept Yes
this information:

4 POSTS BASED IN PRIMARY CARE

Some posts based wholly or partly in Primary Care require applicants to be eligible to join the Dental Performers List for England, NI Dental List
(Northern Ireland), NHS Scotland Health Boards Dental List or the
Dental Performers List in Wales.

It is important you answer the below question accurately.

Will you be eligible to join the above named Dental Lists? Yes

5 TRANSPORT

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You may be expected to provide care away from your base to fulfil the requirements of the training programme. If you do not have access to a vehicle,
you are expected to arrange alternative means of transport at your own expense in order to meet this requirement.
If you do not hold a UK driving licence but plan to drive on an existing EEA/overseas licence, you must ensure that this is valid. The DVLA website has
more information regarding EEA/overseas driving licences (http://www.gov.uk).

Please select the appropriate statement and accept the statement I hold an EEA/overseas driving licence that currently allows
of intent regarding transport. me to drive legally in the UK, but do not have access to a
vehicle for work purposes.

Statement of Intent

I agree that I am able to provide care at any time during my training programme. If for any reason my licence ceases to be valid or I no longer have
access to a vehicle, I agree to provide alternative means of transport at my own expense so that I may continue to fulfil this requirement unless, if I am
unable to drive for medical reasons, my employer is able to make reasonable adjustments to the job or to this requirement.

Please check this box to confirm you agree to the above Yes
Statement of Intent:

6 POSTGRADUATE DEGREES AND QUALIFICATIONS

Please give details of any completed postgraduate dental qualifications/other degrees/diplomas/certificates (e.g. MJDF, MFDS, etc.) Where
a qualification is partly completed please state your exam status (e.g. MFDS Part 1, etc.).

If you do not have any POSTGRADUATE DEGREES AND QUALIFICATIONS please add and enter none

Subject/Qualification Place of Study Grade/Result Date Completed

None

7 ADDITIONAL UNDERGRADUATE DEGREES AND QUALIFICATIONS

Please list any additional completed undergraduate qualifications with dates. Include intercalated BSc/equivalent degree here, if you have
one. Do NOT include details of your pre university school education/exam results.

If you do not have any ADDITIONAL UNDERGRADUATE DEGREES AND QUALIFICATIONS please add and enter none

Qualification Place of Study Grade/Honours Date Completed

University of Ibadan, Ibadan, Oyo

Bachelor of Dental Surgery Pass 23/02/2004
State, Nigeria

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[Supporting information] Supporting

8 REQUEST AN OVERSEAS LOCATION FOR SJT

The Situational Judgement Test (SJT) is delivered throughout the whole of the UK in a large number of test centres. Applicants who are not in the UK
during the SJT window are offered an opportunity to sit the SJT outside of the UK, subject to availability.

Do you need to sit the SJT outside of the United Kingdom? Yes

If you are successful in being invited to attend the SJT, you will be presented with the opportunity to self-book an SJT appointment at a location that is
most convenient for you. To find the centre nearest to your location please visit: Dental Core Training :: Pearson VUE

Ideally, in which city would you like to sit the test? Umuahia, Abia State

Ideally, in which country would you like to sit the test? Nigeria

Please note: this is for information purposes only and does

not guarantee that you will be able to sit the test in this
location.

9 NON DISCLOSURE AGREEMENT

All parts of this selection process are confidential and it is essential that you adhere to confidentiality at all times throughout. This is in
order to maintain the integrity of a valid and reliable selection process.

I understand and agree to the following statements:

I am prohibited from disclosing, publishing, reproducing or Yes

transmitting any of the areas of questioning (SJT and/or interview),
in whole or in part, in any form or by any means including visual,
aural, verbal, written, electronic or mechanical, for any purpose,
without the prior written permission of the DCTNRO.

If I intentionally disclose information relating to any area of the Yes

selection process, I may jeopardise any potential offer made to me
and risk referral to my regulatory body e.g. General Dental Council
or equivalent.

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Application submission
1 Before you submit your application, please make sure that you have reviewed all of your responses to
ensure that you have provided accurate information.

Pressing the submit button at the bottom of this page will automatically submit your application.

By pressing the submit button, you are confirming that you understand that you will NOT be able to add, amend or remove ANY information entered
against the application once the submission has been completed.

Once your application has been submitted, you will be able to view a read-only format of your submitted application from your application summary
screen.

You must have completed all the mandatory field within the application, and reviewed and confirmed the below declaration, in order to submit your
application.

I confirm that I have reviewed the content of my application and, to

the best of my knowledge and belief, the information I have given
in support of my application, including information supplied on this
form and in any attached documents, is true and complete.

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