GP TRAINER APPLICATION FORM GENERAL INFORMATION Name: of Birth: 1.Full 2.Date Address 3.Email (Contact e-mail) Number 4.Telephone (surgery): Address: 5.Home Address 6.Email (personal): Number 7.Telephone (personal): 8. Irish Medical Council Number: _________________________________ □ □ you on the Medical Council Specialist Register for GPs? Yes No 9.Are of Registration on Specialist Register: 10.Date Are you currently a member in good standing of the ICGP or equivalent Body?□Yes□No 11. 12.Name of body: □ □ □ you a Principal/Partner in the Practice? Principal Partner Both 13.Are □ □ you a Full GMS Contract holder?: Yes No 14.Are Contract number (in own name): 15.GMS QUALIFICATION 16.ACADEMIC Qualification Awarding Body Date (Additional qualifications can be added on page 9) GENERAL PRACTICE EXPERIENCE
GP TRAINER APPLICATION FORM GENERAL INFORMATION 1.Full Name: 2.Date of Birth: 3.Email Address (Contact e-mail) 4.Telephone Number (surgery): 5.Home Address: 6.Email Address (personal): 7.Telephone Number (personal): 8. Irish Medical Council Number: _________________________________ 9.Are you on the Medical Council Specialist Register for GPs? □ Yes □ No 10.Date of Registration on Specialist Register: 11. Are you currently a member in good standing of the ICGP or equivalent Body?□Yes□No 12.Name of body: 13.Are you a Principal/Partner in the Practice? □ Principal □ Partner □ Both 14.Are you a Full GMS Contract holder?: □ Yes □ No 15.GMS Contract number (in own name): 16.ACADEMIC QUALIFICATION Qualification Awarding Body Date (Additional qualifications can be added on page 9) GENERAL PRACTICE EXPERIENCE