For an extra - CFEP AU Surveys

1 OPTIONAL: RACGP: 40 Category 1 QI&CPD pts: ACRRM: 30 Extended Skills pts: Please provide details of doctors who wish to participate in this option: Payment has been made for the amount of $ by the following method: FTEs up to 1 FTE 1-2 FTE 2-3 FTE 3-4 FTE 4-5 FTE 5-6 FTE 6-7 FTE 7-8 FTE On Application DISCOUNT PRICE * Registered as: Focused Evaluations Program Pty. Ltd. ACN 074264010 ABN 61 074 264 010. 8-9 FTE 9-10 FTE 10+ FTE STANDARD $271 $409 $568 $673 $779 $884 $990$1096 $1201$1307$236 $357 $496 $587 $679 $771 $863 $955 $1035 $1127 For an extra $85 per GP, your doctor has the opportunity to earn: ALL PRICES INCLUDE GST | Prices above are current for 2017 only Price includes: Survey pack, comprehensive report, additional questionnaires, hard copy of full report (on request) * Discounted price is for returning clients only BANK TRANSFER: Focused Evaluations Program Pty Ltd.

2 BSB 064110; Acc. No. 10276795 (Payment reference should include PRACTICE NAME as written above) CHEQUE: Made payable to: Client Focused Evaluations Program or CFEP Please note: Survey pack will be sent on receipt of application. Final report and Certificate of Completion will not be released until confirmation of payment. PLEASE RETURN THIS FORM TO: Mail: CFEP, PO Box 588, Everton Park QLD 4053 Fax: (07) 3355 7047 Email: For any queries please contact the CFEP office on: Phone: (07) 3855 2093 Email: DR 1: NAME - PRACTICE NAME: (This will appear on the questionnaires) EMAIL - QI&CPD/PDP No.

3 - DR 2: NAME - EMAIL - QI&CPD/PDP No. - DR 3: NAME - EMAIL - QI&CPD/PDP No. - PAYMENT: Total No. of Doctors Hours per/wk : CREDIT CARD: No. of Full Time Equivalent Drs (FTE)**: **Full Time Equivalent (FTE) To meet the RACGP standards , simply add the weekly number of hours worked by each doctor and divide this number by 40. Mastercard Visa Please debit my account.

4 My accounts details are as follows: Card No. __ __ __ __ /__ __ __ __ /__ __ __ __ /__ __ __ __ NAME: (Dr/Mr/Mrs/Ms/Miss) Male Female POST CODE: CONTACT TELEPHONE No.

5 : (Please include area code) EMAIL ADDRESS: ORGANISATION NAME: Please select: AGPAL GPA ADDRESS: (Please note: survey pack will be sent to postal address) PREMISES ADDRESS: POST CODE: POSTAL ADDRESS.

6 CONTACT INFORMATION For example, 96 total doctors hours worked equals The final number is rounded up to the next whole number, so = 3 FTE. RURALITY: (Please select) RA1 RA2 RA3 RA4 RA5(A Bank Service Fee of will be added for all Credit Card transactions) Expiry date:__ __ /__ __ Name on card: SIGNATURE: DATE: STANDARD terms AND conditions FOR SUPPLY OF SERVICES 1 INTERPRETATION In this document the following words shall have the following meanings.

7 "Customer" means any person who purchases Services from the Supplier; "Supplier" means Focused Evaluations Program Pty Ltd trading as CFEP Surveys of PO Box 588, Everton Park, Brisbane Qld 4053; " terms and conditions " means the terms and conditions of supply set out in this document and any special terms and conditions agreed in writing by the Supplier. 2 GENERAL These terms and conditions shall apply to all contracts for the supply of Services by the Supplier to the Customer and shall prevail over any other documentation or communication from the Customer.

8 Any variation to these terms and conditions shall be inapplicable unless agreed in writing by the Supplier. 3 PRICE AND PAYMENT Payment of the price shall usually be paid on application for individual Surveys and by contract or Service Level Agreement terms as applicable. Payment can be made by credit/debit card using the application form or over the phone, by bank transfer or by cheque. Payment in arrears will be by prior agreement only. There will be a separate charge for extra questions and any additional survey material that is requested.

9 The Supplier will send an electronic report to the customer. If any further copies are requested, in any format, there will be an administration charge. The Supplier reserves the right to modify, update or run promotions on any service at any time. The Supplier reserves the rig ht to change the price of any service at any time. Once a service has been ordered, the price shall remain fixed for the Customer. Under no circumstances shall the Supplier refund the difference should the price of that service decrease.

10 4 CUSTOMER'S OBLIGATIONS To enable the Supplier to perform its obligations the Customer shall: Co-operate with the Supplier; Provide the Supplier with any information reasonably required by the Supplier; Keep the supplier notified of their correct name, postal address and any phone, fax or e-mail information. Comply with such other requirements as agreed between the parties. Comply with all other statutory requirements particularly in regards to data protection and confidentiality. 5 SUPPLIER'S OBLIGATIONS The Supplier shall perform the Services with reasonable skill and care and to a reasonable standard in accordance with recognised standards and codes of practice.