Learning & Teaching Application Form 2025/26
 

1. Title *

 

2. Forename *

 

3. Surname *

 

4. GMC Registration Number *

 

5. Mobile Phone Number *

 

6. Email Address
*

 

7. Practice Name *

 

8. Practice Address *

 

9. Practice Tel No *

 

10. Please select which area your Practice is located *

 

11. Practice Manager Name
*

 

12. Practice Manager Email Address
*

 

13. Practice Number/Code (eg Z00234)
*

 

14. Role In Practice (eg Partner/Salaried GP etc)
*

 

15. How many clinical sessions do you work in the practice each week?
 
a. To become a Trainer in the practice, applicants must work 5 or more clinical sessions
OR
b. If the applicant is a second Trainer in the practice, they must work 4 or more clinical sessions
*

 

16. If you are working part-time please describe what arrangements would be put in place for supervision of a trainee? (Trainees can be supervised by a GP Trainer, Salaried GP or a Partner)

 

17. Is your practice a NIMDTA approved training practice for GP trainees?
(If yes please list the GP Trainers)
*

 

18. Regarding the capacity in your practice; how many trainees could you accommodate to train in your practice at any one time? *

 

19. You should be on the Primary Medical Performer’s List in Northern Ireland for at least 1 year post certification. What date were you included on PMPL? *

   DD/MM/YYYY 
 
 

20. Do you have any current undertakings with the GMC or HSCB?

http://www.gmc-uk.org/concerns/doctors_under_investigation/undertakings.asp *

 

21. Relevant Qualifications *

Name of QualificationYear ObtainedAwarding Body
1
2
3
4
5
 

22. Any other information
If there is any other relevant information that you would like to provide to support your application please give details here
(e.g. relevant teaching experience)

 

23. Declaration
Please click 'Yes' to certify that the information given in this application is accurate *