o n l y u s e O f f i c e

Date Received App No No Allocated Approved Comments

General Optical Council Application for registration 2013-14 (individual)

Section 1 Application for registration Please indicate the register in which you wish to be included: The register of optometrists Current GOC registration number The register of dispensing opticians

Section 2 Individual contact details Fields in bold type in this section indicate information which appears in the published register and may be made available to third parties. First name(s) Date of birth Full address Town Country (If not UK) Telephone number Is this address also a practice address? County Postcode Email Yes No Surname Title

Practice address Name of practice Full address Town Country (if not UK) Telephone number County Postcode

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Additional practice address Name of practice Full address Town Country (if not UK) Telephone number County Postcode

Name of practice Full address Town Country (if not UK) Telephone number All practice addresses will appear on the public register and may be made available to third parties. Please continue on a separate sheet if necessary. County Postcode

Section 3 Optical qualifications Educational establishment Qualification Date passed

Year study commenced Name of Supervisor Supervisors GOC no Year pre-reg/PQP training commenced

Completed

Completed

Section 4 Insurance You must hold indemnity insurance cover valid for UK purposes. You must be covered by adequate and appropriate insurance at any time you are working in the UK. You must not carry out any professional work outside the terms of your insurance policy without ensuring alternative cover arrangements are in place. I am covered by the following professional insurance policy/policies: Name of policy holder Insurance company Policy/membership number

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Section 5 - Declarations Do you wish to make any declarations?

Yes No

Please give full details below Failure to provide full details will delay your application Please proceed to section 6

Section A Criminal and disciplinary proceedings 1. Please provide full details of any convictions or cautions (or any Agreed Offer, Penalty Payment Agreement, or Absolute Discharge Order in Scotland) or any investigations in relation to a criminal offence. You must declare any conditional caution, and any convictions which led to the imposition of a conditional or absolute discharge. This must include any convictions etc that you believe spent. You should give full details of the date, the offence committed, the penalty or punishment imposed and the circumstances leading to the offence. This should include the amount of any fine and the name of the court you attended. Attach a separate sheet if necessary. You do not need to declare road traffic offences that have been dealt with by way of a fixed penalty.

2. Please provide details of any adverse findings or current investigations by the GOC or any other body which regulates a health or social care profession either in the UK or abroad, including an NHS primary care organisation (PCO) or health board. You should give details of the date, the regulatory body/PCO and the sanction or investigation. Attach a separate sheet if necessary.

Section B Physical and mental health Are you aware of mental or physical health conditions which a reasonable person would think might impair your fitness to practice? If yes, please provide full details of the date and nature of the condition, the date of diagnosis and any treatment required.

Continue on a separate sheet if necessary.

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Section 6 Identification
Attach photo here and sign on front

I certify that I have known the applicant for at least two years and that the attached photograph, which is identified by my signature, is a true likeness. Name of applicant Name of person certifying Position of person certifying Signed Section 7 Declaration of information I declare that I have read, understood and will comply with the GOCs Code of Conduct for individual registrants. I understand that the GOC will use the information I have provided to exercise its proper and statutory functions. I declare that the information given in this form is true and accurate. I understand that my annual retention application will be due by 15 March each year regardless of the date of my registration. I understand that I must notify the GOC immediately if there are any changes to the information provided in this application. Signed Date Date

Official stamp

Section 8 Certification (to be completed by your examining body) I certify that the applicant has satisfied the requirements of this examining body and is competent to practice. Name of person certifying Position of person certifying Examining body (College of Optometrists/Association of British Dispensing Opticians/University of Manchester*) Signed Section 9 Payment Please tick the relevant box in order to indicate your method of payment of the registration fee. I have included a cheque payment, made out to GOC for the sum of I have paid by bank transfer and the reference used is as follows: Ref Date

I wish to make payment by card over the telephone. Please contact me on daytime telephone number in order to take my card details.

Please tick this box if you have enclosed a low income application form with your restoration form.

Office use only

Fees Received Initials Date

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Checklist
Complete all sections of the application form Attach a photo signed across the front by the person certifying your identity Enclose payment to cover the 260. You may be entitled to a pro-rata rate of registration. Please see the attached guidance notes for further information. You may be entitled to apply for the low income reduced fee. If so, please enclose the low income reduced fee application form. Please see the attached guidance notes for further information. Sign and date the application You must return the form to your examining body according to their instructions. It is your responsibility to ensure that your registration form arrives at the GOC and that your name is entered on the GOC register.

General Optical Council Guidance notes for registration 2013-14 (individual)

To apply for registration you need to do four things: 1. Complete all sections of the registration form and sign and date the declaration 2. Attach a signed photograph 3. Enclose the registration fee, (260 for the full year or a pro-rata fee if you are eligible) 4. Return the form and payment to your examining body Section 1 Application for registration Tick the box to identify which register you wish your name to be entered. Provide your existing GOC number. Your name will be removed from the student register on successful application to the full register. If applicable, your entry in the register of dispensing opticians will be removed on successful application to the register of optometrists. Section 2 Contact details You must provide an address which is reliable so that communications from the Council can reach you without delay. You must notify the Council of any changes to your address in writing or by using the MyGOC area on the GOC website. You should also notify us of any change of name as soon as possible, enclosing a photocopy of the change of name deed or marriage certificate. Practice addresses provided for publication in the register should include the name under which you intend to practice at that address. If you need more space, please continue on a separate sheet of paper. Section 3 Optical qualifications Please include all qualifications on which you rely for registration. Unless annual subscriptions are made to the College of Optometrists or Association of British Dispensing Opticians, professional qualifications granted by these organisations cannot be shown in the register. Section 4 Insurance Registrants arranging their own insurance should provide full policy details. Members of the Association of Optometrists should record AOP as the insurer with their membership number. Members of the Association of British Dispensing Opticians who hold ABDO insurance should record ABDO as the insurer and their policy number or full policy details. Section 5 Declarations Please ensure that you either tick the YES or NO box to indicate whether you wish to make any declarations about criminal and disciplinary proceedings and/or physical and mental health. If you tick YES you must provide full details in section A and/or B according to the guideline below and on the form. You must declare any conviction, caution, conditional caution, conditional or absolute discharge and any investigations in relation to a criminal offence. This must include any of the above that you believe spent. Relevant bodies for the purposes of section A2 are the following: General Optical Council General Chiropractic Council General Dental Council General Medical Council General Osteopathic Council Health and Care Professions Council Nursing and Midwifery Council Pharmaceutical Society of Northern Ireland General Pharmaceutical Council Primary care organisations or health boards

Section 5 Declarations (continued) For full guidance, please refer to the declarations guidance available on the GOC website at http://www.optical.org/en/Registration/Making_declarations. If you are unable to access this document, please contact us directly using the contact details below. Section 6 Identification A signed photograph is a key part of the application. The person certifying your identity must have known you for at least two years and they must sign the front of the photograph and complete and sign the identification section. This person cannot be a member of your family. The photograph can be signed by: registered optometrist/ registered dispensing optician; registered medical practitioner; registered solicitor or barrister: justice of the peace; principal of an educational establishment which granted the applicant a qualification or a person authorised by the principal of that establishment; or another person of similar standing in the community. Section 7 Declaration of information Please sign and date the form in the space provided. Section 8 Certification (to be completed by your examining body) This section must be completed by your examining body, i.e. the College of Optometrists, the Association of British Dispensing Opticians or the University of Manchester. If your application form arrives at the GOC without this section having been completed it may be returned to you, leading to a delay in your application. Section 9 Payment The registration fee for 2013-14 is 260, although you may be eligible for a pro-rata rate for registration. The pro-rata rate for registration is available to all applicants who are on the student register at the time of applying for registration on the full register. The pro-rata rates for 2013-14 are as follows:
Date added to register Fee Payable Apr-Jun 2013 260 Jul-Sep 2013 195 Oct-Dec 2013 130 Jan-Mar 2014 65

In addition you may be eligible for the low income reduced rate of registration. The fee is available to all registrants whose total income from all sources during the registration year is less than 12,000. If you think you may be eligible for this please submit an application form for the low income fee by downloading a copy of the form from the GOC website. Please note that the low income fee will also be available pro-rata. For further information, please refer to the information available on the website or call the Registration Department on the number below. We can accept payment by cheque, credit/debit card or bank transfer. Cheques should be in pounds sterling, drawn on a bank based in the UK and made payable to the General Optical Council. Eurocheques will not be accepted. Write your name and GOC number on the back of your cheque. If you wish to pay by card, please provide a daytime contact number and we will call you to collect payment. When making a bank transfer use your name and GOC number when providing the bank with a reference code for the transaction. Record this reference code and date of payment on the application form or on a cover note attached to the form. Once your application for registration has been processed your name will then be added to the relevant register. You must renew your registration each year by submitting an online application for retention. Your annual retention fee will be due by 15 March regardless of the date of your registration. The registration year runs from 1 April to 31 March. If you have any questions Email Write to Telephone Website registration@optical.org 41 Harley Street, London W1G 8DJ +44(0)20 7580 3898, option 1 Mon to Thurs 09.00-17.00, Fri 09.00-16.45 www.optical.org