SCHEDULE 3

Part IIIInformation and undertakings to be provided by the existing partners in relation to an application to practise in partnership

2

Particulars of each existing partner who will form part of proposed new partnership, including—

a

name and cypher number;

b

whether practising as—

i

a full-time doctor;

ii

a three-quarter-time doctor;

iii

a half-time doctor; or

iv

a job-sharing doctor;

c

age;

d

number of persons on list;

e

proposed partnership shares, dates and exclusions (if any)—

i

commencing;

ii

first share change;

iii

second share change; and

iv

third share change;

f

time spent on other health service appointments or health service administration, including—

i

number of sessions;

ii

type of appointment; and

iii

average weekly hours; and

g

time spent on regular non-health service appointments (eg Medical Referee, Police Surgeon, Occupational Medicine etc), including—

i

type of appointment; and

ii

average weekly hours.