GP SUPERVISOR MEMBERS

1.Please provide your contact details, include and email address that is unique to you.

This information will be used by GPSA to deliver targeted communication about GP Supervisor specific information and will not be provided to a third party.

First Name^*

Surname^*

Gender

Female
Male
Non-binary

Different gender identity

Date of Birth

I am an active Supervisor in a practice accredited to train GP Registrars

How long have you been a GP Supervisor?

Who is your local Regional Training Organisation

Fellowship

RACGP Fellow
ACRRM Fellow

Do you identify as Aboriginal and/or Torres Strait Islander

Please specify if personal or work address

Personal Address
Work Address

Address

Street Number

Street Address

City

State

Country

Zip Code

Email^*

Mobile phone

Practice Name^*

Practice manager name

Practice manager email

Username^*

I would like to receive GPSA e-communications.

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GP Supervisor form

GP SUPERVISOR MEMBERS

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