*1.Full Name(Required.)

*2.Contact email(Required.)

*3.GMC number(Required.)

*4.Name of practice (if you are a locum this can be any practice within the LLR area that you have worked in during the past year)(Required.)

*5.Practice code(Required.)

*6.Area standing for(Required.)

Leicester City

Leicestershire County (inc West and East)

Rutland

*7.Current Position(Required.)

GP Partner/Principle

Sessional GP (Salaried GP & GP locum)

*8.Are you a Newly Qualified GP (completed CTT within the last 5 years)(Required.)

Yes

No

*9.Nomination statement (maximum 2000 characters with spaces)(Required.)

*10.I can confirm that I have read and understood the below corporate LMC documents:

• LLR LMC Board Role description
• Nolan Principles
• Code of Conduct & Conflict of Interest Policy
• LLR LMC Constitution

(Required.)

Yes