General Practice Fellowship Role Expression of Interest Form

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* 1. Name (title/ first name/ surname)

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* 2. Email address

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* 3. Mobile phone number

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* 4. Address

Address

Address 2

City/Town

Postal Code

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* 5. Name of employing practice

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* 6. Which borough is the practice based?

Barnet

Camden

Enfield

Haringey

Islington

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* 7. Name of manager or lead partner

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* 8. Contact for manager or lead partner

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* 9. Contract type: Full-time/Part-time

Full-time

Part-time

If part-time, how many days/hours per week?

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* 10. Are you interested in applying for the new to practice fellowship (tier 1)?

Yes

No

If yes, please state the date that you began employment as a general practice nurse:

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* 11. Are you interested in applying for the nursing fellowship for established nurses (tier 2)?

Yes

No

If yes, please state the number of years that you have worked in general practice:

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* 12. How would you hope to use your experience as a General Practice Nursing Fellow to support your practice/PCN/Community? (150 word limit)

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* 13. How would you hope to use your experience as a General Practice Nursing Fellow in your future career? (150 word limit)

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* 14. Would you be happy for us to store your information and to contact you in the future?

Yes

No