GP RETAINER SCHEME FIRST APPLICATION FORM PART A: Personal Details (to be completed before interview with regional adviser) Surname First Name Home Address Post Code Home telephone Email and/or mobile GMC Number CCT or JCPTGP Number Qualifications & Dates Eligibility Career Plans Please attach a brief CV (1 side of A4 should be adequate) PART B: Practice Details (to be completed following practice employment interview) Proposed start Number of date sessions per week (2 4 per – week) The Retainer Scheme starts on the 1st of a month Total duration on the Scheme is 5 years Name of Approved as a Last Educational GP Trainer approval Supervisor (Y/N) date Practice Address Approved as a Last Retained approval Doctor date Educational Supervisor (Y/N) Practice Code Practice Type (GMC or PMS) Practice Mobile of Telephone RD/ES Name of Practice Tel Direct Dial Manager Practice Manager Educational Email Address Supervisor Email Address PART C: Work and Educational Arrangements (to be completed following practice employment interview) 1. What induction is planned for you within the practice?
GP RETAINER SCHEME FIRST APPLICATION FORM PART A: Personal Details (to be completed before interview with regional adviser) Surname First Name Home Address Post Code Home telephone and/or mobile Email GMC Number CCT or JCPTGP Number Qualifications & Dates Eligibility Career Plans Please attach a brief CV (1 side of A4 should be adequate) PART B: Practice Details (to be completed following practice employment interview) Proposed start date Number of sessions per week (2 – 4 per week) The Retainer Scheme starts on the 1st of a month Total duration on the Scheme is 5 years Name of Educational Supervisor Approved as a GP Trainer (Y/N) Last approval date Practice Address Approved as a Retained Doctor Educational Supervisor (Y/N) Last approval date Practice Code Practice Type (GMC or PMS) Practice Telephone Mobile of RD/ES Name of Practice Manager Tel Direct Dial Practice Manager Email Address Educational Supervisor Email Address PART C: Work and Educational Arrangements (to be completed following practice employment interview) 1. What induction is planned for you within the practice?
new-retainer-scheme-form-2.docx