APPLICATION FORM FOR PART 2 OF THE PLAB TEST Once you apply to sit a PLAB examination, the information

you provide will be used to update, administer and maintain your record, process complaints, compile statistics, and send you relevant material. We supply data to the Department of Health, professional, educational and training bodies so that they can correct their own information and compile statistics. PLEASE COMPLETE THIS FORM IN CAPITAL LETTERS PLEASE NOTE INCOMPLETE FORMS WILL DELAY ALLOCATION TO A TEST DATE When completing this form, please refer to Advice to candidates for Part 2 of the PLAB test and the list of examination dates. This can be accessed from the website (www.gmc-uk.org) or by phoning the GMC enquiry line on +44 (0)8453 573456, or email plab@gmc-uk.org. GMC Reference Number: Family Name: First Name: Other Names: Address:

Telephone: Mobile: E-mail:

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Please indicate below the dates on which you would like to take the examination. Please enter dates for five different examinations. Your application may be delayed if you do not do this. Please note that where the examination is run over two days we cannot guarantee on which day you will be allocated a place. For example, you may not put your first choice as 9 October 2002 and your second choice as 10 October 2002 as these dates are for the same examination. Date 1. 2. 3. 4. 5. Place

I hereby declare that: The information given in this application is true and accurate. I understand that if a test admission letter is sent to me, I will be charged a cancellation fee if I decide to postpone or cancel my test place.

Signed: . Date: ... To give you quick access to your test results we will publish them on the Internet. If you do not wish us to do this, please tick this box. Please return this form and fee of 430 (payable to the General Medical Council by cheque or sterling bankers draft, money order or postal order) to the Registration Directorate, General Medical Council, 178 Great Portland Street, London, W1W 5JE.

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