ROYALCOLLEGE OF GENERAL PRACTITIONERS

PANEL OF EXAMINERS AND ASSESSORS

MAP APPLICATION FORM

Surname:…………………………………………………………………………………..

Forename(s): ………………………………………………………………………………

Address for correspondence: (Home/Surgery - please delete as appropriate)

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Other address: ……………………………………………………………………………………………..

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Telephone:Work: ………………………………… Mobile: ……………………………………………..

Email address: ………………………………………………………………………..
MRCGP/FRCGP (please delete as appropriate) Faculty: ………………………………………

Please state if MRCGP by Exam or by other means (and state means): ……………….

Please state if current MRCGP examiner and/or date of AKT pass: ……………………………………….

Date on which you became a Member of the College: ……………………………………………

Please note you are required to be a Member or Fellow in good standing

Postgraduate experience: …………………………………………………………………………………….…

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Years in general practice: …………………………

Present appointment and working practice (e.g. partner / salaried / locum) – general practice, other relevant posts, (e.g. hospital, industrial):

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Teaching experience – undergraduate, vocational training, other: ………………………………………..

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Other relevant experience – e.g., Appraisal, LMC, CCG, other:

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Please explain how feel you meet the requirements for this role in a maximum of 500 words.

See the Assessor Role Description for essential attributes and principle responsibilities.

Data Protection Act

I understand that information requested will be used by the College for administrative purposes, and to meet its statutory obligations.

Signed: ………………………………………………… Date: …………………………………………..

Please give the names and addresses and positions of three referees, who will support your application, from three of the following categories:

  1. Either a partner in the applicant’s own practice
    or a Principal in general practice who is familiar with the applicant’s clinical work;
  2. A Director of Postgraduate General Practice Education, or Associate Dean, or GP Tutor, or clinical governance lead;
  3. A current member of the Panel of Examiners, or an Officer of the applicant’s Faculty Board, or a Fellow of the RCGP.
  4. The Medical Director or equivalent responsible for locum/out of hours or other GP servicewho is familiar with the applicant’s clinical work.

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Telephone: ……………………………………………………………………..

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Telephone: ……………………………………………………………………..

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Telephone: ……………………………………………………………………..

Equal Opportunities Monitoring

The Royal College of Practitioners is committed to a policy of equality for its members in accordance with the Race Relations (Amendment) Act, Disability Discrimination Act and other legislation. Please complete the following section with this in mind:

1 Gender. Female Male (please tick)

2 Date of birth. ..…/..…/….…

3Ethnic group. To which ethnic group do you belong?

(please tick one box only)

WHITEBLACK / BLACK BRITISH

BritishCaribbean

IrishAfrican

Any other White backgroundAny other Black background

ASIAN / ASIAN BRITISHMIXED

Indian White and Black Caribbean

PakistaniWhite and Black African

BangladeshiAny other Mixed background

Any other Asian background

OTHER ETHNIC GROUP

Chinese

Any other ethnic group

4Disability.

Do you have a disability? Yes  No (please tick)

(under the Disability Discrimination Act a disability is defined as physical, sensory or mental impairment which has, or had, a substantial and long-term adverse effect on a person’s ability to carry out normal day-to-day activities)

If yes, please indicate which of the following categories describes your disability:

Wheelchair user

Person with physical disabilities

Visually impaired person

Hearing impaired person

Person with dyslexia

Person with speech impairment

Other disability