MFFLM and LFFLM Part 2 Examination Application Form – 2024 Examination application form This form is for all FFLM exams: DLM, LFFLM & MFFLM Parts1 & 2 Step 1 of 4 25% About YouBy applying for any of the FFLM exams you confirm that you have read the updated Regulations of the exam you are applying for and you meet the application eligibility criteria. You confirm that you have also read the Exams page of our website and the subpages that are relevant to your exam. Note Part 1 and DLM exams are in October (application time in June). And the Part 2 exams take place in March and June (application time in November).* I confirm I have read the updated examination regulations and meet the application eligibility criteria. I have also read the relevant sections of the exams page on the website.Name (Do not use ALL capital letters please)* Prefix DrMissMrMrsMsProf.Rev. First Last Do you have any former name (before Deed Poll change, single or maiden name) or any name you are also known as?*YesNoFormer Name(s) Email*A personal email address, rather than a work one, is preferable. This is due to the fact that we may need to email you near the time of your exam, and we may not be able to get through to you if you are off on study leave, for example. Enter Email Confirm Email Address* Street Address Address Line 2 City Postcode Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Preferred Contact Number*Date of Birth* DD slash MM slash YYYY What is your current post?* What is your specialty?* Who is your employer? If self employed please let us know below.* Profession Doctor Nurse Paramedic Dentist Coroner Barrister or Solicitor Professional Registration Body (e.g. GMC, GDC, NMC, HCPC) What is your professional registration number (or equivalent body) number (if relevant)?*GMC, NMC, HCPC etc What year did you obtain full registration?* Regarding your primary qualification, what is your degree (MD, MBBS etc)?* When was it conferred?* What was the issuing university?* Where (city and country)?* Examination you intend to sitWhich exam are you applying for?*DLM (available only in October)Part 1 MFFLM (available only in October)Part 1 LFFLM (GFM) (available only in October)Part 1 LFFLM (SOM) (available only in October)Part 2 MFFLM (GFM) (available only in March)Part 2 MFFLM (GFM) SAQ only (available only in March)Part 2 MFFLM (GFM) OSCE only (available only in March)Part 2 MFFLM (SOM) (available only in March)Part 2 MFFLM (SOM) SAQ only (available only in March)Part 2 MFFLM (SOM) OSCE only (available only in March)Part 2 MFFLM (MLM) (Not available in March 2024)Part 2 MFFLM (MLM) OSPE only (not available March 2024)Part 2 LFFLM (GFM) (available only in March)Part 2 LFFLM (SOM) (available only in March)Is this your first attempt?*Multiple attempts are allowed for the DLM and the Part 1 exams but for the Part 2 ones only four are allowed.YesSecondThirdFourthIf you are applying for the MFFLM exam, should you pass it, in which area do you plan to sit your Part 2 exam?*GFMSOMGFM + SOMMLMIt is your responsibility to notify the FFLM Office of any special requirements in writing at the time of application. Applications for special arrangements on medical or compassionate grounds must be supported with medical certification.You should not assume that previously agreed special arrangements will be carried forward to a future examination. We expect to be notified of any request at each examination attempt. Details of any agreed special arrangements will be recorded electronically and used for monitoring the effectiveness of the FFLM’s processes. Please specify requested arrangements below. Equality & DiversityThe information on this page is collected for equality monitoring and is optional. However we do appreciate your completing it to help us ensure we are meeting our equality and diversity requirementsWhat is your gender? Female Male Prefer not to say Ethnic origin (see next five questions below)Asian/British AsianBlack/Black BritishChinese or other ethnic groupMixed heritageWhiteOtherNationalityUnited KingdomAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsFirst language Where did you graduate? Do you have a disability within the meaning of the Equality Act 2010? (The Equality Act defines a person as having a disability if they have a physical or mental impairment that has a substantial and long-term effect on his or her ability to carry out normal day to day activities.)* Yes No Nature of disability (optional)If the answer to the above is yes, would you be prepared to specify how this might impact on your exam and how we could support you.Sexual orientation"Straight/Heterosexual" means that you're only attracted to people of the opposite sex "Gay or Lesbian" means that you're attracted to people of the same sex "Bisexual" means that you're attracted to more than one sex "Other sexual orientation" lets you give your own answer, for example, pansexual or asexual. Straight/Heterosexual Gay or Lesbian Bisexual Prefer not to say What is your religion, if any? No religion Christian (all denominations) Buddhist Hindu Jewish Muslim Sikh Have you prepared for your exam using any of the tools below? Please tick all that apply. e-Learning Webinars Face-to-face courses Additional InformationFor MFFLM and LFFLM candidates only: if you are applying for the Part 1 exam, should you pass it, are you planning to apply for the Part 2 that will take place next March?YesNoMaybeFor LFFLM SOM Part 2 candidates only: which exam are you applying for?Please note that nurses may only apply for the "Adult" option.LFFLM (SOM) - all 14 stationsLFFLM (SOM) (a) (adults only) - 11 stations onlyLFFLM (SOM) (c) (children only) - 11 stationsWhen did you pass your Part 1 exam - or obtained DLM with Distinction?Part 1 exam results are valid for four years.October 2023October 2022October 2021October 2020For LFFLM (SOM) and LFFLM (GFM) candidates only: Has your Compendium of Validated Evidence (COVE) or your Case Portfolio been approved? Please also write below when. At least one of them has to have been submitted (pending approval) before you apply for the exam.YesNoFor Part 2 candidates only: would you be interested in attending a revision day for the exam you have applied for? If yes, we will contact you once revision dates have been scheduled.YesNoIs there anything else you would like to inform the FFLM about? For example, is someone paying for your exam fee on your behalf? Please do not choose the option Direct Debit.If your employer or friend/partner is paying for your fee please let us know so we can locate your payment easily.Accuracy of information* I confirm that the information provided on this application is true and accurate to the best of my knowledge. I agree to the declarations and to the privacy policy. Now that you have finished filling in your form, please click on Submit, below. If you have not yet paid for your exam fee, using the appropriate link on the Exams page, please do so now as your application is only complete once we have received your form and your payment.
