Regulation 5(2)
1. Full name.
2. Sex.
3. Date of birth.
4. Private Address and telephone number.
5. Medical qualifications and where obtained.
6. Declaration that he is a registered medical practitioner, included in the Medical Register in that name.
7. Registration number in the Medical Register and date of first registration.
8. Whether applying to succeed to a practice, or be appointed to a vacancy in a practice.
9. Notification of the geographical boundary of the applicant’s proposed practice area by reference to a sketch, diagram or plan.
10. Notification of address(es) of proposed practice premises.
11. Whether the applicant intends to practise as—
(a)a full-time doctor;
(b)a three-quarter-time doctor;
(c)a half-time doctor;
(d)a job-sharing doctor; or
(e)a restricted doctor.
12. Where the applicant intends to practise as a job-sharing doctor, the name of the other job-sharing doctor with whose hours the applicant’s hours are to be aggregated for the purposes of regulation 15(1)(d).
13. Notification of proposed days and hours of attendance.
14. Telephone number(s) at which prepared to receive messages.
15. Undertaking that if accepting as a patient a person who at the time of acceptance or succession is residing at a place outside the practice area he will visit him at that address.
16. Proposed place of residence (including telephone number and distance from main surgery) and an undertaking to inform the FHSA whenever changing permanent residence.
17. Whether or not on the medical list for the FHSA’s locality.
18. If not in the FHSA’s medical list, present or most recent appointment, and if in general practice, whether as principal, assistant or locum.
19. Professional experience (including starting and finishing dates of each appointment) separated into:
(a)trainee or assistant experience in general practice;
(b)general practice experience;
(c)hospital appointments;
(d)other (including obstetric) experience;
(e)any additional supporting particulars.
20. The name and address of principal to whom trainee or assistant.
21. Particulars of covenants restricting medical practice by the applicant in the FHSA’s locality.
22. Name and address of any intended partner and whether or not the name is included in the FHSA’s medical list.
23. Names and addresses of two referees.
24. If applicant is not in the FHSA’s medical list—
(1) name of any other FHSA in whose list he is included;
(2) particulars of any outstanding application for inclusion on the medical list of any FHSA;
(3) information about general medical services to be provided and, in particular, whether—
(a)including excluding | maternity medical services limited to |
(b)including excluding limited to | contraceptive services |
(i)excluding including | fitting of intra-uterine including devices |
(ii)restricted not restricted | to patients to whom the doctor or partner provides other personal medical services |
(c)including excluding limited to | child health surveillance services |
(d)including excluding limited to | minor surgery services |
(4) whether or not applied/intending to apply for—
(a)inclusion in minor surgery list,
(b)inclusion in child health surveillance list,
(c)inclusion in obstetric list; and
(5) undertaking to be bound by terms of service.