GPO Education Program Application

2 Week Introductory Module Only:

*This form is for applicants who wish to attend only the 2 week Introductory Module of the GPO Education Program.

APPLICANT DETAILS

NAME OF APPLICANT:

First Name, Middle Initial, Last Name

ADDRESS

Street # and name, City, Province, Postal Code

TELEPHONE NUMBERS:

Home:

Office:

Mobile:

EMAIL ADDRESS:

INTRODUCTORY MODULE YOU PLAN TO TAKE:

September 9 - 20, 2019

February 3 - 14, 2020

BRIEFLY STATE YOUR REASONS FOR WANTING TO TAKE THE PROGRAM:

CAREER GOAL

POST GPO EDUCATION PROGRAM CAREER GOAL:

Palliative Care Physician
Other – please specify

CURRENT PRACTITIONER INFORMATION

Name of your licensing body:

Are you a member in good standing?	Yes No

REQUIRED ATTACHMENTS

PLEASE INCLUDE THE FOLLOWING WITH YOUR APPLICATION:

Letter of support from your program director or equivalent (as appropriate)

If you are not providing the above, please include a personal statement outlining your rationale for	wanting to take the program

Current Curriculum Vitae

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, Program Manager

Family Practice Oncology Network

BC Cancer

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.

GPO Education Program Application	2

Mahil, Dilraj

2019-02-22

Hewlett-Packard Company