FPM Concessionary rate application form

FACULTY OF PHARMACEUTICAL MEDICINE

of the Royal Colleges of Physicians of the United Kingdom
Concessionary Rate Application Form 2020
FPM member number:
Name:*

First NameLast Name
Email*
example@example.com
A. Reduced rate (£125.00)
The Reduced rate applies to those members who have no paid engagements in pharmaceutical or other medical practice or those members who are earning less than £15,000 per annum from pharmaceutical or other medical practice due to unemployment, part-time employment, parental leave, illness or other reasons. Fellows, Members, Associates and Affiliates are eligible for this concessionary rate.
B. Out of practice rate (£65.00)
The Out of Practice rate applies to those members who have no paid engagements in either pharmaceutical or clinical practice and have retired completely from medical practice. Fellows, Members and Affiliates are eligible for this concessionary rate.
Confirm your concessionary rate and sign declaration.
I wish to apply for A. Reduced rateI wish to apply for B. Out of practice rate
I declare that I am eligible for this concessionary rate to the best of my belief and knowledge.
Signature (use cursor to sign electronically)*

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