Further Extension of Training Application

AGPT APPLICATION –FURTHER EXTENSION OF TRAINING TIME

Purpose

This application is for a registrar who is seeking a further extension of training time as per the AGPT Extension of Training Time Policy 2017.

Instructions

This application can be filled out electronically or handwritten. Please ensure the declarations on page two of this application are signed by the registrar and Regional Training Organisation.

The Regional Training Organisation is to submit this application to the Department of Health on the registrar’s behalf. Submissions from the registrar without Regional Training Organisation approval on page two of this application will not be accepted by the Department of Health.

IMPORTANT:All sections of this application must be completed. Please give consideration to providing supporting documentation/evidence with your application.

Registrar details

Title:

First name:

Surname:

AGPT Registrar number:

Email:

Mobile number:

Regional Training Organisation name:

Reasonfor seeking a further extension of training time

Registrar declaration

I declare I have discussed this proposal with my Regional Training Organisation and agree to the application for a further extension of training time as per the AGPT Extension of Training Time Policy 2017. I declare the information provided in connection with this application is true and correct.

Signature: [Registrar to sign]

Print name:

Date:

Regional Training Organisation declaration

I declare we have discussed this proposal with the above mentioned registrar and support this application for a further extension of training time as per the AGPT Extension of Training Time Policy 2017. I declare the information provided in connection with this application is true and correct.

Signature: [CEO or delegate to sign]

Print name:

Date:

Lodgement

Please email this application to your Regional Training Organisation for approval. If this application is for a further extension of training time beyond the extensions specified in Clause 5 of the AGPT Extension of Training Time Policy 2017 please email the application to the Department of Health for consideration at

Privacy Statement

Your personal information is protected by law, including the Privacy Act 1988, and is being collected by the Department of Health for the purpose of administering the Australian General Practice Training Program. If you do not provide this information, the Department will be unable to manage your training. You can get more information about the way in which the Department will manage your personal information, including the Department’s privacy policy available on the AGPT website.

AGPT Application –Further Extension of Training Time

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