Personal Details

1

Surname (used in training)

2

First Name

3

Other Surname (if different from surname used in training)

4

GMC / GDC Number

5

Email Address

6

Phone Number

7

Are you a Tier 2 / Skilled Worker Visa Holder?

LTFT Eligibility Reason / Circumstance

8

Trainees with a disability or ill

9

Trainees (men and women) with caring responsibilities

10

Welfare and wellbeing

11

Unique opportunities

12

Religious commitment

13

Non-medical development

14

Flexibility for training and career development

Proposed placement and Training Plan

15

Proposed LTFT Placement and Training Plan

16

Level you will be working at

17

Name of Training Programme

18

LTFT Start date

19

LTFT End date (if known)

20

Proposed Percentage

21

Applicant Declaration