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
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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
jennifer.wolfe@bccancer.bc.ca
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.
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