Intra-Deanery Transfer Application Form Name Current address Telephone number Mobile telephone number Email address Date of Appointment to GPST Current Scheme GMC Number Requested Scheme(s) Do you have any geographical restrictions as to where you can work in the requested scheme(s)? If yes, please give details. Expected date of completion of GPST Date you wish transfer to take place TRAINING REQUIREMENTS: Please confirm how much further training (whole time equivalent) you will GP require in order to complete your GP training from the Requested transfer date(in months) TRAINING REQUIREMENTS: Please confirm how much further training (whole time equivalent) you will Hospital require in order to complete your GP training from the Requested transfer date(in months) POSTS COMPLETED AS PART OF GP Training (Please include any periods of sick leave (over 10 days in one If LTF time please ST year) and maternity/paternity leave) supply Start Date End Date percentage Specialty (please include hospital or practice name):
Intra-Deanery Transfer Application Form Name Current address Telephone number Mobile telephone number Email address Date of Appointment to GPST Current Scheme GMC Number Requested Scheme(s) Do you have any geographical restrictions as to where you can work in the requested scheme(s)? If yes, please give details. Expected date of completion of GPST Date you wish transfer to take place TRAINING REQUIREMENTS: Please confirm how much further training (whole time equivalent) you will require in order to complete your GP training from the Requested transfer date(in months) GP TRAINING REQUIREMENTS: Please confirm how much further training (whole time equivalent) you will require in order to complete your GP training from the Requested transfer date(in months) Hospital POSTS COMPLETED AS PART OF GP Training (Please include any periods of sick leave (over 10 days in one ST year) and maternity/paternity leave) Specialty (please include hospital or practice name): If LTF time please supply percentage Start Date End Date
Intradeanery-request-form-1.docx