HSC Research & Development        
Personal and Public Involvement 
EXPRESSION OF INTEREST

Please complete and return this form by post or email to HSC R&D of the Public Health Agency at the address below. You will then be contacted to arrange an interview.  	
Title & Name
(Mr, Mrs, Ms, Dr. etc)		
Home Address and Tel No.

		
E-mail address		
Working Career/
Occupation (if relevant)

Membership of organisations, posts held and dates 

Relevant skills and experience.

relevant skills and experience continued…

	Please say here what you believe you are able to bring to the role of Personal and Public Involvement Representative in HSC R&D. Highlight the relevant skills and experiences you have gained through your own experience or illness. 

	
Other interests and activities

	 

	
Referee (please provide the name and address of an individual who would be relevant to this application)
	How do you know this person (e.g. employer, on same committee, work colleague, personal):	

Signed:		

Date:		

Please return to:  Gail Johnston
                              Programme Manager (PPI)
                              HSC R&D
                              Of the Public Health Agency
                              12-22 Linenhall St
                              Belfast
                              BT2 ABS

	        Telephone: 028 9536 3490
                 Email: gail.johnston@hscni.net