University of Wales College of Medicine
Part1 : To be completed by the Applicant
Please complete this part of the form (IN BLOCK CAPITALS), then send it to your referee requesting that the reference be returned to us at the address given below:
Your Full Name:--------------------------------------------------------------------
Correspondence Address:------------------------------------------------------------


Nationality: ----------------------------  Date of Birth: -------------------------
Medical School:  ------------------------  Date of Qualification:  ----------------
PostGraduate Qualifications: ------------------------------------------------------
Proposed Course:    Diploma in Practical Dermatology
Date of Commencement: -------------------------------------------------------------
Name of Referee: ------------------------------------------------------------------
Part2: To be completed by the Referee
The above named doctor has applied to undertake the Diploma in Practical Dermatology course. The applicant has given your name as a referee and I would be grateful if you could send me, in confidence, your opinion as to the candidate's suitability for this course of study. The course uses distance learning techniques requiring the doctor to work in a self disciplined manner at home over a total of 30 weeks.

We would be grateful if you could let us have your opinion and any other relevant information at your earliest convenience.

In considering applications, the Selection Comittee attaches a great importance to the information which is provided in references and we should like to thank you in advance for your assistance. Your reply will be treated in the strictest confidence by the University of Wales College of Medicine.

Please send the completed form direct to the following address:

Sonia van Lierop,
Postgraduate Courses Co-ordinator,
Department of Dermatology (Box 27),
University of Wales College of Medicine,
Heath Park,
CF14 4XN

Applications are not normally processed until a referee has been received.

1. How long have you known the applicant and in what capacity?

2. The applicant's general suitability for this course of study, including any distinct strengths or weaknesses.
(Please continue on a seperate sheet if necessary.)
Name of Referee: -------------------------------------------
Title/Status: ----------------------------------------------
Address: ---------------------------------------------------
Signature: ------------------------------  Date: -----------