Regulation 5(6)
1. Full name of applicant.
2. Copy of the applicant’s application to the FHSA.
3. The names of any proposed partners and/or members of the applicant’s group practice.
4. Copy of any declaration of partnership, or intent to practise in association with a group practice.
5. The date from which the applicant proposes to provide the services in question.
6. Confirmation that the applicant is eligible to be included in the child health surveillance list or the minor surgery list as the case may be.
7. The area of the FHSA’s locality in which the medical services in question are to be provided.
8. The name of any other FHSA in whose locality the applicant provides or intends to provide the medical services.
9. The area of any other FHSA’s locality in which the applicant provides, or intends to provide, the medical services.
10. Whether or not the application is supported by the FHSA, including details of its reasons for supporting or not supporting the application and any report from the Local Medical Committee or Community Health Council.
11. A statement that the FHSA has confirmed that the applicant is a registered medical practitioner and that his name as entered on the application is currently included in the medical register.
12. A statement that the applicant is a British or European Community national, or, if not, that the FHSA has checked that the applicant is entitled to work as a self-employed practitioner in the United Kingdom.
13. Any other information which the FHSA considers to be relevant to the determination of the application, including any unusual factors that may affect demand for the particular services in question.
14. If the Medical Practices Committee so request, details of the numbers of doctors on the Medical List already providing the services in question in the area of locality of the FHSA where the applicant proposes to provide the service.