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* 1. Name of applicant

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* 2. Contact details:

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* 3. GMC number

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* 4. Are you on the National Medical Performers List?

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* 5. Qualifications and dates.

Please state any relevant mentoring, education or training qualifications you hold, including the awarding organisation.

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* 6. In which NCL borough do you currently work?

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* 7. How many clinical sessions do you work in primary care each week? (The minimum for this role is 3 sessions per week)

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* 8. What other educational roles do you currently hold?

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* 9. Scheme application

What are your personal objectives in applying to this scheme?

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* 10. Describe how your professional experience will help you provide a mentee with appropriate support including links to other local resources.

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* 11. What personal experience have you had of working or learning in an environment where you were different from your peers and how has this influenced your practice?

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* 12. Give an (anonymous) example of a mentor relationship, whether formal or informal, where you have provided effective mentorship support for a colleague in a professional role.

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* 13. What can make a mentorship relationship challenging and how would you approach these issues?

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* 14. Please provide the details of two professional references to support your application.

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* 15. Practice details:

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* 16. I understand that if I am accepted to undertake this role, I will need to commit to being available for 2 sessions per month in addition to my 3 Clinical sessions which may include 1:1 mentoring ,group facilitation and some (virtual) training days, as needed.

If I secure and confirm a place on this scheme and fail to attend any funded accredited ILM5 training that I agree to commit to, I will be charged the course fee

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