General Practice Fellowship Application

Date of Application*

Name of Practice*

Town/City*

Practice Code*

PCN*

Practice Contact Name*

Practice Contact Position*

Practice Contact Email*

Practice Contact Phone Number*

Name of Fellow:*

Gender

Fellow's Email Address*

Fellows Role: (select from dropdown)*

Which VTS was/is Fellow part of?*

If other, please enter VTS name

Date of Qualification (click to select from calendar):*

Contract Start Date (click to select from calendar):*

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 CPD and development time
Permit the fellow to attend monthly education programme sessions organised by the Training Hub in protected CPD 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:

Email

This field is for validation purposes and should be left unchanged.