1. Details

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* 1. Name

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* 2. GMC Number

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* 3. Date you started training

Date

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* 4. Date you left / consider leaving training

Date

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* 6. Are you Full Time or Less Than Full Time?

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* 7. What would be your stage of training at the point of leaving

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* 8. Core Training Pathway

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* 9. Specialty Training Pathway (if applicable)

T