Reinstatement of FPM membership

Reinstatement of FPM membership

Please complete all sections and submit with a copy of your current curriculum vitae.
Personal details
Full name (as recorded on the medical register)*

TitleFirst name(s)Last name
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 (to match with previous record in FPM database)*
Contact details
Main email address (required)*
Alterantive email address (optional)
Personal phone number (required)*
Work phone number (optional)
Preferred phone number*

Personal phone numberWork phone number
Home Address (required)*
Home postcode / zip code*
Home country*
Job title
Company name (optional)
Company Address
Company postcode / zip code
Company country
Preferred mailing address*

Home addressCompany address
Medical registration and CV

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.
GMC UK registration number
Non-UK medical registration number
Non-UK medical registration country
If you are not registered with the UK GMC, please upload proof of your medical registration here

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Current curriculum vitae*

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Cancelof
Subcription fee and concessionary rates

Our subscription year runs from January to December, so we will pro rata the amount if you re-join part way through the year (see Declaration below). We will send you an invoice along with confirmation of your membership if you are reinstated.

Information on fees, including the concessionary rates application form, is available on fees and payments.
Do you want to request a concessionary membership subscription rate?

NoYes, I have submitted a concessionary rate application form
Declaration

I would like to reinstate my membership of FPM as indicated, and declare that the information given on this form is true to the best of my belief and knowledge. I agree to pay the current year subscription fee (or pro rata), the rejoining fee and any outstanding fees due at the date of the deletion of my membership. I hereby consent to being admitted to membership of FPM and faithfully promise to abide by the Articles of Association of the Faculty and the Laws, Bye-Laws, Statutes and Regulations of the Colleges as they apply to members of the Faculty to Pharmaceutical Medicine.
Signature of applicant (use the cursor to sign your name)*

Clear
Important: Prescribed connection

If you have a UK licence to practise and have no other current legal prescribed connection, membership of FPM may create a prescribed connection for revalidation. Should your membership reinstatement be approved please consult the GMC’s tool to establish where your legal prescribed connection lies. If you are uncertain about any aspect of your prescribed connection please contact the Revalidation team at revalidation@fpm.org.uk
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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Reinstatement of FPM membership

Personal details

Contact details

Medical registration and CV

Subcription fee and concessionary rates

Declaration

Important: Prescribed connection

Data protection