GPO Training Program Application

advertisement
GPO Training Program Application
2 Week Introductory Module Only:
A Two Week Lecture Series in Oncology Education for Primary Care Practitioners
*This form is for applicants who wish to attend only the 2 week Introductory Module of the GPO Training Program.
APPLICANT DETAILS
NAME OF APPLICANT:
Last Name, First Name, Middle Initial
ADDRESS
Street # and name, City, Province, Postal Code
TELEPHONE NUMBERS:
Home:
Office:
Mobile:
EMAIL ADDRESS:
INTRODUCTORY MODULE YOU PLAN TO TAKE:
February 23 – March 6, 2015
September 14 – 25, 2015
BRIEFLY STATE YOUR REASONS FOR WANTING TO TAKE THE PROGRAM:
CAREER GOAL
POST GPO TRAINING PROGRAM CAREER GOAL:
Palliative Care Physician
Other – please specify
GPO Training Program Application 2015
1
CURRENT PRACTITIONER INFORMATION
MEDICAL SERVICES PLAN (MSP) PRACTITIONER #:
Permanent #
Temporary # – Expiry Date
Other – Explain
COLLEGE OF PHYSICIANS & SURGEONS OF BC LICENSE #:
Permanent #
Temporary – Expiry Date
Other – Explain
Are you a member in good standing?
Yes
No
CANADIAN MEDICAL PROTECTION ASSOCIATION (OR ALTERNATE) #
NON PHYSICIANS ARE REQUIRED TO PROVIDE EQUIVALENT INFORMATION: Explain
REQUIRED ATTACHMENTS
PLEASE INCLUDE THE FOLLOWING WITH YOUR APPLICATION:
A letter of support from your program director (if applicable)
If you are not including the above letter, please include a personal statement outlining your rationale for
wanting to take the program.
Curriculum Vitae with all your current and previous appointments listed
SUBMIT YOUR APPLICATION BY EMAIL
Ensure all documentation is available prior to submitting your application. Please email your complete application –
including all attachments – as one PDF document (with this application form at the front) to:
Jennifer Wolfe
Family Practice Oncology Network
BC Cancer Agency
600 W. 10th Ave.
Vancouver, BC V5Z 4E6
T: 604 219 9579
[email protected]
Kindly submit your application at your earliest convenience. We thank you for your interest and will advise you promptly
as to your acceptance into the program.
GPO Training Program Application 2015
2
Download