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PLAB1

PLAB Part 1
application form Before submitting this application please
see the following pages on our website at
www.gmc-uk.org:
You should use this application form if:
0 ‘Before you Apply’ in the Guidance
0 You want to apply to take Part 1 of the PLAB test for PLAB test candidates
and are unable to book a place online
0 International Medical Graduates
- important information

Please state below why are you unable to book a


place online: The information you give on this form will
be used by the GMC to:

0 Process your application

0 Process complaints

0 Compile statistics and undertake


research

0 Send you GMC guidance and


other information.
Please write clearly in black ink and use capital letters

You do not need to provide documents with this application form. They will be checked at a later stage.

You must complete all sections of this form marked with a *. If the form is incomplete it may be returned to
you.

Fee

Please enclose the correct fee of £ 230 with your application. If you hold refugee status please see our website (www.gmc-uk.org)
or contact us for the appropriate fee.

Posting your application form

Please post your completed application to:

General Medical Council, PLAB test section, 3 Hardman Street, Manchester M3 3AW
Your personal details
(If you do not have a GMC reference number, we will allocate you one when
GMC reference number we receive your application.)

Family name or surname*

First name*

Other names

Date of birth* D D M M Y Y Y Y Gender*

Your contact details


Full address*

Postcode* Country*

Home telephone* Work telephone Mobile telephone

Email

Your nationality and passport details


Nationality*

Passport number

City or town of issue Country of issue

Date of issue D D M M Y Y Y Y Date of expiry D D M M Y Y Y Y

Refugee status
(If you hold Refugee status in the UK please tick one option below)

Holders of a British passport cannot claim refugee status.


I am a refugee doctor and enclose an original letter from the Home Office as evidence of my status in the UK
stating that I have been given one of the following:
a) Refugee status and I am recognised as a refugee under the 1951 UN convention 
b) Indefinite leave to remain in the UK (with refugee status) 
c) Indefinite leave to enter (with refugee status) 
d) Exceptional leave to remain in the UK (granted prior to 1 April 2003) 
e) Humanitarian leave to remain (Also known as humanitarian protection. Granted on or after 1 April 2003) 
f) Discretionary leave to remain (With no restrictions on working, granted on or after 1 April 2003) 
This form was last updated in June 2015. Please make sure that you are using the most up-to-date version of the form.
To obtain a current form telephone us on 0161 923 6602 (or +44 (0) 161 923 6602 if calling from outside the UK). Page 2 of 7
English language declaration*
(Please tick one option below.)
I have passed the academic version of the International English Language Testing System (IELTS)
a)
(Please provide details below)

Test date DD/MM/YYYY Test report form number 


Academic Academic
Listening Speaking Overall
Reading Writing
I am a new graduate and obtained my primary medical qualification (PMQ) from a university where the
b) 
language of instruction and examination is English.
I am not a new graduate and obtained my PMQ from a university where the language of instruction and
c) examination is English and have practised continuously for the two years immediately preceding this 
application in a country where the language of professional practice is English.
I have passed an English language test for the purposes of obtaining registration with one of the medical
d) regulatory authorities indicated on your website and I have continuously practised in that country for the 
two years immediately preceding this application.
You must provide evidence to prove your English language declaration. Please see our website (www.gmc-uk.org) for more information.

Your primary medical qualification (In most cases your primary medical qualification is your first medical degree.)

Full title of your primary Name and full address (including Date training Date training Date
medical qualification* country) of the university (and college started* finished* qualification
if appropriate) that awarded your awarded
qualification*

DD/MM/YYY DD/MM/YYY
DD/MM/YYYY
Y Y

Further information about your primary medical qualification *

PMQ1 Have you studied for your primary medical qualification at any medical school other than the one YES/NO
that awarded the qualification? (If yes please provide details below.)

Other medical schools you have attended Date training Date training
started finished
DD/MM/YYY DD/MM/YYY
Y Y
DD/MM/YYY DD/MM/YYY
Y Y
DD/MM/YYY DD/MM/YYY
Y Y
Has any part of your primary medical qualification been undertaken by remote or distance
PMQ2 learning? (eg a period of study undertaken solely by internet or through correspondence-based YES/NO
learning)
(If yes please provide details on a separate sheet.)
Is your primary medical qualification acceptable for the purpose of registration in the country that
PMQ3 awarded your qualification? (eg subject to internship, further training or examination) YES/NO
(If no please provide details on a separate sheet.)

PLAB test place*


Indicate below the dates and venue(s) that you would like to sit the PLAB test

1. Date D D M M Y Y Y Y Venue

2. Date D D M M Y Y Y Y Venue

3. Date D D M M Y Y Y Y Venue
This form was last updated in June 2015. Please make sure that you are using the most up-to-date version of the form.
To obtain a current form telephone us on 0161 923 6602 (or +44 (0) 161 923 6602 if calling from outside the UK). Page 3 of 7
British (English/Welsh/Scottish/Northern Irish)  Irish

Gypsy or Irish Traveller

Any other white background (please write in)

White and Black Caribbean  White and Black African

White and Asian

Any other mixed background (please write in)

Indian  Pakistani

Bangladeshi  Chinese

Any other Asian background (please write in)

Caribbean  African

Any other black background (please write in)

Arab

Any other ethnic group (please write in)

Prefer not to say

This form was last updated in June 2015. Please make sure that you are using the most up-to-date version of the form.
To obtain a current form telephone us on 0161 923 6602 (or +44 (0) 161 923 6602 if calling from outside the UK). Page 4 of 7
Your diversity details

The GMC is committed to treating everyone fairly and meeting our legal responsibilities under the Equality Act 2010 and
related legislation (such as the Human Rights Act 1998). One of the ways we do this is by asking people to provide
information about their ethnicity, disability, gender, sexual orientation, religion and beliefs.
Giving us this information is optional. If you choose to give it to us, we will keep it confidential and hold it securely in line
with data protection and other relevant legislation. We will use the information you give us to analyse and report on
statistical trends in medical education and practice in the UK. We will anonymise/pseudonymise any data we publish so
you can’t be identified.
The information may be used by different teams at the GMC. We may also share your personal data with other parties
if required by law, where ordered by a court, or where it is otherwise in the public interest (for example for research
purposes). Where possible, data will be anonymised or pseudonymised before we share it with any other party.
This information will not be shared with teams that make a decision about your application or your fitness to practise.
Help with categories

Ethnicity
• 'White British' includes the categories of White English, White Welsh, White Scottish and White Northern Irish.

Disability

The Equality Act 2010 defines a person as disabled if they have a physical or mental impairment, which has a substantial
and long-term (i.e. has lasted or is expected to last at least 12 months) and adverse effect on the person’s ability to
carry out normal day-to-day activities.
Religion and belief
The list of categories includes all the options from the census 2011 for England, Northern Ireland, Wales and Scotland.

Ethnic origin

White

 British (English/Welsh/Scottish/Northern Irish)  Irish

 Gypsy or Irish Traveller

 Any other white background (please write in)

Mixed

 White and Black Caribbean  White and Black African

 White and Asian

 Any other mixed background (please write in)

Asian or Asian British

 Indian  Pakistani

 Bangladeshi  Chinese

 Any other Asian background (please write in)

This form was last updated in June 2015. Please make sure that you are using the most up-to-date version of the form.
To obtain a current form telephone us on 0161 923 6602 (or +44 (0) 161 923 6602 if calling from outside the UK). Page 5 of 7
Black or Black British

 Caribbean  African

 Any other black background (please write in)

Other ethnic group

 Arab

 Any other ethnic group (please write in)

Prefer not to say


 Prefer not to say

Religion and belief

 No religion  Christian - Other

 Buddhist  Christian - Presbyterian

 Christian - Baptist  Christian - Protestant

 Christian - Brethren  Hindu

 Christian – Catholic  Jewish

 Christian - Church of England  Muslim

 Christian - Church of Ireland  Sikh

 Christian - Church of Scotland  Other

 Christian - Free Presbyterian  Prefer not to say

 Christian - Methodist

Sexual orientation

 Bisexual  Other

 Heterosexual/straight  Prefer not to say

 Lesbian/Gay

Disability
This form was last updated in June 2015. Please make sure that you are using the most up-to-date version of the form.

To obtain a current form telephone us on 0161 923 6602 (or +44 (0) 161 923 6602 if calling from
outside the UK). Page 6
of 7
 No disability or long-term illness  Learning disability - e.g. dyslexia

 Disabled but prefer not to give details  Mental illness e.g. depression

 Blind or sight loss  Speech impairment

 Deaf or hearing loss  Cognitive disability - e.g. brain injury, autism

 Mobility - e.g. difficulty walking short distances or  Other impairment - e.g. epilepsy, asthma, cancer or
climbing stairs facial disfigurement

 Manual dexterity  Prefer not to say

Final Declaration*
I confirm that the information I have provided in this application is correct and true.

I understand that any false declaration in any part of this application or false information or documentation provided in support
of this application may result in the GMC withholding or removing my registration, even if I have passed the test.

I confirm that I have read and understood the Guidance for PLAB test candidates on your website.

I understand I may be charged a cancellation fee if I decide to cancel or change my test place.

I understand that a decision about the acceptability of the qualification will not be made until the GMC have received an
application for registration. The criteria for acceptability change from time to time and that means that I could take the
PLAB test but find that my qualification is not acceptable for the purposes of registration. Full details of the current criteria
can be found on the GMC website.

I understand that by presenting to sit the PLAB Part 1 exam I declare myself fit to sit the exam.

I will be required to produce evidence of my identity when I attend for Part 1 or 2 of the PLAB test. This must be in the form
of my passport, or United Kingdom Immigration and Nationality Department Identification Document, or a home office
travel document, or a United Kingdom driving license. The evidence must bear my photograph.

My photograph will be taken when I attend for Part 2 of the PLAB test for future verification of my identity.

My personal data, including my photograph, and any of the information I provide to the GMC may be:

0 disclosed to Government agencies, employers, overseas regulators (including outside the EEA) and other
third parties where required by our procedures, by law or as may be reasonably necessary
0 used by the GMC, their representatives, and any other agent that the GMC ask to carry out checks on its behalf,
to make any necessary checks to verify the information I have given, including checks on my English language
proficiency, employment, qualifications and the accuracy of any information provided
0 used by the GMC and its partners for research purposes

Signature*

Date*
This form was last updated in June 2015. Please make sure that you are using the most up-to-date version of the form.
To obtain a current form telephone us on 0161 923 6602 (or +44 (0) 161 923 6602 if calling from outside the UK). Page 7 of 7