Incomplete applications will be rejected.Applicant's organisation * REQUIRED Applicant's name * REQUIRED First Last Email * REQUIRED Mobile numberWork group(s) required GHC Inpatients GHC Cheltenham ICT GHC Cotswold ICT GHC Stroud ICT GHC Gloucester ICT GHC Forest of Dean (Tewkesbury, Newent & Staunton ICT) Type of access required * REQUIRED Read Only Access SmartCard Full Access SmartCard Read Only Access Username and Password Full Access Username and Password (write to record) SmartCard Number Lawful Reason for Access * REQUIREDHow will you ensure lawful access? * REQUIREDJustification * REQUIREDSharing benefits * REQUIREDInformation risk sharing * REQUIREDDuration required Access will be granted for 12 months, re-viewable thereafter, unless less time is requiredConfirmation * REQUIRED I have read and understood the access guide and agree to abide by its terms CAPTCHA