Fellowship in General Practice Application

Please complete all fields below and click the submit button once you have finished. (If your form does not submit, please scroll up to check for any missing red fields.)

If you have any queries, please email candptraininghub@nhs.net or call us on 01733 666670.

Fellowship in General Practice Application Form

Date of Application*
DD slash MM slash YYYY
Name of Practice*
Town/City*
Practice Code*
PCN*
Practice Contact Name*
Practice Contact Position*
Practice Contact Email*
Practice Contact Phone Number*
Fellows Role: (select from dropdown)*
Name of Fellow:*
Fellow's Email Address*
Date of Qualification (click to select from calendar):*
DD slash MM slash YYYY
Contract Start Date (click to select from calendar):*
DD slash MM slash YYYY
Contracted Working Time*

GP: Number of sessions per week / Nurse: Number of hours per week
Length of contract if not permanent

eg. 1 year, maternity cover etc
Pay Rate*

GP: Sessional Rate per Year £s / Nurse: Hourly Rate £s
Name of Practice Mentor*
Practice Mentor Position*
Practice Mentor Email Address*
Practice Commitment*
- Provide and deliver a supported induction programme
- Assign a named in-house mentor and agree to a minimum of protected mentorship time
- 1 session per week (WTE pro rata) identified as protected learning and development time
- Permit the fellow to attend monthly education programme sessions organised by the Training Hub in protected learning time
Please check all boxes to confirm your agreement.
Name/Signature*

(Practice Manager or Senior GP)
Signee Position*
How did you hear about this scheme?*
Please specify: