QPP Verfication Status Form

CONFIDENTIAL VERIFICATION OF STATUS Verification of HIV+ status by a GP or a HIV specialist / HIV service provider is essential for any person applying for ordinary class of membership of QPP. ONLY ORDINARY CLASS OF QPP MEMBERSHIP IS ENTITLED TO VOTE.... More

CONFIDENTIAL VERIFICATION OF STATUS Verification of HIV+ status by a GP or a HIV specialist / HIV service provider is essential for any person applying for ordinary class of membership of QPP. ONLY ORDINARY CLASS OF QPP MEMBERSHIP IS ENTITLED TO VOTE. I,………………………………………………………………………………………... (name of GP or HIV specialist / HIV service provider) □ General Practitioner □ HIV specialist / HIV service provider certify that the applicant ………………………………………………………………………………………….. (name of person applying for ordinary membership of QPP) is known to me to be HIV+. Signature: ………………………………………………………………………....... (signature of GP or HIV Specialist) Date: ………………………………… Please place practitioner stamp over signature Less