New to Practice Application Form

Name:

Email:

Name of Practice:

Town/City of Practice:

Practice Code:

Practice Manager Name:

Practice Manager Email Address:

Fellow Role:
—Please choose an option—GP - SalariedGP - PartnerNurse
CCT/Graduation Date:

GMC Number (or NNC/GPN equivalent):

Date of Application:

Contract Start Date:

Clinical Sessions/Week (if GP):

Contracted hours (if GPN):

Pay Rate (Sessional rate if salaried GP; internal locum sessional rate if GP partner; Hourly rate if GPN):

Have you previously been part of a New to Practice Fellowship programme in another area?
—Please choose an option—YesNo
Please confirm your previous Host Training Hub:

Please confirm your previous Host Practice:

Please confirm your previous Practice Manager name and email address:

Please confirm your dates of starting/leaving previous role:

Please confirm total number of full months salary reimbursement received to date:

Please confirm your practice lead / PM has agreed to your participation in the Devon NTP Fellowship.:
I have discussed my application with my Practice Manager, and have their approval to proceed with this application
My Practice Manager supports the above GP/GPNs application to participate in the Devon NTPF Programme
My Practice Manager is aware I need 1 session a week identified as protected learning and development time
My Practice Manager permits the NTP fellow to attend monthly NTP session organised by DTH