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N Name of candidate: Medical Council Number: This person worked under my supervision from: To: Clinical Site: Country: Specialty: Grade (e.g. Intern, SHO): Are you in anyway related to the applicant? Yes _____ No ____ Relationship: Please complete the following sections based on the following marking system: 1 = poor 2 = inadequate 3 = satisfactory 4 = above average 5 = excellent It is expected that most candidates will score “3”. Only exceptional candidates should score “4” .

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