Agpt application program leave



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AGPT APPLICATION - PROGRAM LEAVE

Purpose


This application is a registrar who is seeking leave from the Australian General Practice Training Program as per the AGPT Program Leave Policy 2017.

Instructions


This application can be filled out electronically or handwritten. Please ensure the declarations on page two of this application are signed by the registrar and Regional Training Organisation.

The Regional Training Organisation is to submit this application to the Department of Health on the registrar’s behalf. Submissions from the registrar without Regional Training Organisation approval on page two of this application will not be accepted by the Department of Health.

IMPORTANT: All sections of this application must be completed. Please give consideration to providing supporting documentation/evidence with your application.

Registrar details


Title:

First name:

Surname:

AGPT Registrar number:

Email:

Mobile number:



Regional Training Organisation name:

Dates seeking leave


Start:

End:

Type of leave (Please mark)


Exception to the AGPT Program Leave Policy 2017

☐ Category 2 leave – where the Regional Training Organisation is unable to place registrar


Reason/s for seeking leave




Reason/s Regional Training Organisation was unable to place the registrar (if applicable)




Detail the Regional Training Organisation’s efforts to locate a placement (if applicable)







Registrar declaration


I declare I have discussed this proposal with my Regional Training Organisation and agree to the application for an exception to the AGPT Program Leave Policy 2017. I declare the information provided in connection with this application is true and correct.

Signature: [Registrar to sign]

Print name:

Date:

Regional Training Organisation declaration


I declare we have discussed this proposal with the above mentioned registrar and support this application for an exception to the AGPT Program Leave Policy 2017. I declare the information provided in connection with this application is true and correct.

Signature: [CEO or delegate to sign]

Print name:

Date:

Lodgement


The Regional Training Organisation is to lodge this application to the Department of Health on behalf of the registrar. Please email the completed application and supporting documentation to the Department of Health for consideration at AGPTManagement@health.gov.au

Privacy Statement


Your personal information is protected by law, including the Privacy Act 1988, and is being collected by the Department of Health for the purpose of administering the Australian General Practice Training Program. If you do not provide this information, the Department will be unable to manage your training. You can get more information about the way in which the Department will manage your personal information, including the Department’s privacy policy available on the AGPT website.

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