Affiliate membership application form

Affiliate membership application form
Personal details
Full name (as recorded on the medical register) *

Title (Dr etc) First name Middle name(s) Last name
Please read the Affiliate membership eligibility criteria before completing the application form. Complete all sections and submit with a copy of your current full curriculum vitae (CV).
Known as (if applicable)
Let us know if your preferred first and/or last name are different to the above and we will use these in communications with you.
Date of birth *
(DD/MM/YYYY)
Sex *

Female Male Prefer not to say

Medical registration

You must be currently registered with the GMC or the relevant professional body in the country in which you are practising or where you were awarded your primary medical qualification.
UK GMC registration number
Non-UK medical registration number
Non-UK medical registration country
If you not registered with the UK GMC, please upload proof of your medical registration here

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Primary medical qualification

Your medical school and qualification must be listed in the WHO Directory.
What is your primary medical qualification? *
At which University did you take your primary medical qualification? *
Include the name of the University and the country
In what year were you awarded your primary medical qualification? *
(DD/MM/YYYY)

Connection to pharmaceutical medicine
When did you start working in Pharmaceutical Medicine (if applicable)?
(DD/MM/YYYY)
Please provide information on your current professional interest and connection with pharmaceutical medicine *
Please let us know why you are applying for Affiliate membership *
Upload your curriculum vitae and any other relevant information *

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Declaration

I would like to apply for Affiliate membership of the Faculty of Pharmaceutical Medicine (FPM) as indicated, and declare that the information given on this form is true to the best of my belief and knowledge. I hereby consent to being admitted to membership of FPM and faithfully promise to abide by FPM's Articles of Association and Regulations and the Laws, Bye-Laws, Statutes and Regulations of the Parent Colleges as they apply to members of the Faculty of Pharmaceutical Medicine.
Signature of applicant (use the cursor to sign your name) *

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Data protection

The Data Protection Act requires organisations or agencies collecting personal data on individuals to gain their consent before collecting, storing, publishing or analysing their data. By completing and signing this application for membership of FPM you are giving your consent for your data to be stored and used by FPM. All data will be treated with the strictest confidence and will only be used for legitimate FPM purposes, see our Privacy Policy.
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Declaration