Special Approved Placements Program Request - Coversheet and Checklist Personal details Full name (Please provide name as stated on AHPRA public record) Medical registration number and category Australian residency status Existing Medicare provider number (if held, first six digits only) Contact number (business hours) Application Requested practice location(s) 1. 2. (Please provide full name and 3. street address) Reason for applying for Category A Exceptional circumstance claim – approved placement Category B Removed from other full-time – program Category C Removed from RLRP 2 Year Program Tick only one – Category D Aus trained doc seeking experience – Category E OTD with limited med reg – Category F Emergency respondent – Request type New placement request Request for extension of placement Add location Change location SAPP placements (if applicable) Approved practice location(s) 1. 2. (Please provide full name and 3. street address) Expiry date of placement (DD/MM/YYYY) Supporting evidence checklist Current medical registration Attached (compulsory) Employment contract Attached (compulsory) GP experience assessment Attached Not attached Reason if experience assessment not provided
Special Approved Placements Program Request - Coversheet and Checklist Personal details Full name (Please provide name as stated on AHPRA public record) Medical registration number and category Australian residency status Existing Medicare provider number (if held, first six digits only) Contact number (business hours) Application Requested practice location(s) (Please provide full name and street address) 1. 2. 3. Reason for applying for approved placement Tick only one Category A – Exceptional circumstance claim Category B – Removed from other full-time program Category C – Removed from RLRP 2 Year Program Category D – Aus trained doc seeking experience Category E – OTD with limited med reg Category F – Emergency respondent Request type New placement request Request for extension of placement Add location Change location SAPP placements (if applicable) Approved practice location(s) (Please provide full name and street address) 1. 2. 3. Expiry date of placement (DD/MM/YYYY) Supporting evidence checklist Current medical registration Attached (compulsory) Employment contract Attached (compulsory) GP experience assessment Attached Not attached Reason if experience assessment not provided