Fellowship Application Form Fellowship Application Form 12Nominee Details3Professional Practice4Appraisal & Revalidation5Declaration on Complaints6References7Declaration Fellowship of the Faculty of Forensic & Legal Medicine is open to those who have held Membership of the Faculty for at least 5 years or in the case of Foundation Members those who have been eligible for Membership for at least 5 years. In exceptional cases awarding of Fellowship may be considered prior to this, however it is for the Membership and Fellowship Committee & the Board to determine if they feel the application meets this criteria. Information submitted via this form will be used to carry out any reasonable activity related to the administration of the FFLM Fellowship process and is held subject to relevant data protection legislation. This form is designed to allow those seeking Fellowship or nominating colleagues for Fellowship to provide information to support the application. Failure to complete all sections may result in rejection of the application as this information is essential to the Membership and Fellowship Committee (MFC) in determining whether to recommend to the Board that an individual is awarded Fellowship. The application will be judged based on the information within this form. Thus, insertion or attachment of a Curriculum Vitae (CV) is not sufficient for a valid application. Candidates for Fellowship should ideally nominate themselves, however may be nominated by existing Fellows.Criteria To be considered for Fellowship of the Faculty of Forensic & Legal Medicine of the Royal College of Physicians individuals should: Have been a member (or been eligible for Foundation Membership) for at least 5 years. In exceptional circumstances applications prior to 5 years may be considered Be in good standing with the Faculty Promote and comply with the values and aims of the Faculty Provide details of two Members or Fellows who have agreed to provide references supporting the application Demonstrate how activity in their own professional field has furthered the objectives of the Faculty. The Faculty would hope that those individuals appointed to Fellowship will act as ambassadors for the aims and values of the FFLM in raising standards in forensic and legal medicine and protecting vulnerable people. Key Points All applications are reviewed and assessed by the MFC who may take advice from regional and specialty advisers, or from international advisers if appropriate. It is a thorough but confidential process, which does not involve the candidates directly but evaluates their suitability for election. Following a decision by the MFC a recommendation will be made to the Board. After the relevant Board meeting, the Registrar writes to the nominee to inform them of the outcome. If the outcome is unfavourable the candidate can be proposed again in subsequent years. They are not brought forward automatically by the Faculty and so the onus is on a proposer to submit a new proposal form. The Proposal will normally be considered at the next appropriate meeting of the MFC. Dates of these meetings are on the Faculty website. Nominee DetailsName* MrMrsMissMsDrProf.Rev. Title Forenames (in full) Surname Date of Birth* Day Month Year Email* Phone*Category applied for*Forensic PractitionerDento-Legal AdviserMedico-Legal AdviserMedically Qualified CoronerMiscellaneousMedical Reviewer/Medical ExaminerProfessional Registration Body (e.g. GMC, GDC, NMC, HCPC)*Professional Registration Number (e.g. GMC, GDC, NMC, HCPC)*Address for Confidential Correspondence if relevant Street Address Address Line 2 City County Postcode Fellowships/Memberships of other colleges or societiesHonours, Degrees or Qualifications where relevant (including date awarded)Please add Qualification, Awarding Body and Date Awarded. Professional PracticeRole 1Job titleEmployerYear started DD slash MM slash YYYY Average Hours Per WeekRole 2Job titleEmployerYear started DD slash MM slash YYYY Average Hours Per WeekRole 3Job titleEmployerYear started DD slash MM slash YYYY Average Hours Per WeekPlease indicate the areas under which you feel this application for Fellowship should be considered Academic & Research Innovation & Creativity Leadership Professional Practice Teaching & Education Personal StatementUnder each of the categories selected above please outline specific examples where the nominee has furthered the objectives of the Faculty in protecting vulnerable people and raising standards in forensic and legal medicine. Your referees should be able to attest to these contributions. (no more than 6000 characters) Exceptional ContributionFor nominations requesting consideration of election to Fellowship within 5 years of membership please explain why this application merits consideration of exceptional contribution. (no more than 1800 characters) Appraisal & RevalidationRevalidation Date DD slash MM slash YYYY Date 1 DD slash MM slash YYYY Date 2 DD slash MM slash YYYY Date 3 DD slash MM slash YYYY Date 4 DD slash MM slash YYYY Please upload most recent Form 4/ Appraisal Summary Drop files here or Select files Max. file size: 8 MB. Declaration on ComplaintsAs part of the application you are asked to declare any pending or upheld formal complaints, disciplinary procedure, litigation or referrals to your regulatory bodies. Please tick yes or no below:* Yes: I DO have outstanding or previously upheld complaints regarding litigation, disciplinary, professional conduct or performance to declare. Please provide details by emailing charlene.campbell@fflm.ac.uk. No: I DO NOT have any pending complaints or upheld formal complaints to declare. Please give details IN CONFIDENCE on the Declaration of Complaints form (on the website) and send to registrar@fflm.ac.uk). Any declarations made will remain strictly confidential and not be shared beyond the MFC.If this situation should change before the date of the MFC, I undertake to inform the Faculty promptly in writing ReferencesEach referee should be a Member or Fellow of the Faculty of Forensic and Legal Medicine. They will be sent a copy of this form and be requested to attest to the achievements described above as well as confirm their support of the application for FellowshipReferee 1 DetailsName MrMrsMissMsDrProf.Rev. Title First Last Daytime Contact NumberEmail Referee 2 DetailsName MrMrsMissMsDrProf.Rev. Title First Last Daytime Contact NumberEmail DeclarationsI confirm that the details provided in this application are correct & that I have read, understood, and agree to the FFLM privacy policy. I also give permission for the Faculty to perform checks with my employers and/or my regulatory body for any outstanding performance issues likely to bring the Faculty into disrepute. Should I be invited to join the Faculty of Forensic and Legal Medicine I agree to uphold its values. Please tick to confirm you have read and accepted the form of faith* I have read and accepted the Form of Faith Privacy Policy* I agree to the declarations above and to the privacy policy.I confirm that the details provided in this application are correct & agree to the Faculty contacting the referees listed above in support of this application. I also give permission for the Faculty to perform checks with my employers and/or my regulatory body for any outstanding performance issues likely to bring the Faculty into disrepute (if this form is not completed by the nominee they will be asked separately to complete this declaration and the declaration of complaints should the MFC agree to Fellowship in principal). Should I be elected to Fellowship of the Faculty of Forensic and Legal Medicine I agree to uphold its values (if this form is not completed by the nominee they will be asked separately to complete this declaration and the declaration of complaints should the MFC agree to Fellowship in principal). PhoneThis field is for validation purposes and should be left unchanged.
