Educational Supervisor (ES)

This form can be used to set up a payment plan. Please note you will be required to pay by direct debit.

Name*
First Last
Email*
Location*
Registered body*
- GMC
- HCPC
- NMC
Registration Number*
Qualifications:*
Specialist or General Practitioner registration MFFLM or LFFLM Postgraduate Certificate – Advanced Forensic Practice (Sexual Assault and/or Custody)
Date of ES training*
DD slash MM slash YYYY
ES training provider*
Confirmation that role of ES is included in appraisal with reflection and CPD activity*
Good standing*
Confirmation that ES is in good standing with the above mentioned registered body
Electronic signature*
Please tick this box to confirm the information you have provided is correct.