Fellowship Referee Declaration Form Referee Declaration Form Fellowship 12Nominee Details3Referee Details4Referee Declaration Fellowship of the Faculty of Forensic and 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. Nominee DetailsName* MrMrsMissMsDrProf.Rev. Title First Last Referee DetailsName* MrMrsMissMsDrProf.Rev. Title First Last Daytime contact numberEmail GMC/GDC Number Address for Confidential Correspondence if relevant Street Address Address Line 2 City County Postcode Supporting StatementPlease provide a brief statement in support of the information cited in the nominees application form. You may also wish to detail your relationship with the candidate and your perceptions of his or her working style, achievements, and commitments. Referee DeclarationI have reviewed the information provided in support of the candidate’s application and attest to the accuracy thereofI have reviewed the information provided in support of the candidate’s application and attest to the accuracy thereof Yes No I am willing to be contacted by the Faculty of Forensic & Legal Medicine to discuss any part of this application. I note that a Fellow of the Faculty of Forensic & Legal Medicine is someone who: Has significantly furthered the objectives of the Faculty in their professional field. Promotes and complies with the values and aims of the Faculty Has made a significant impact on the service in the field of their appointment or practice Has been a Member of the Faculty in good standing for five continuous years at the date of registration or, in the case of Foundation Members, have been eligible to hold the MFFLM for five years. If you would like to provide any information in confidence, please contact the Registrar of the Faculty. I know of no reason why the candidate should not be considered for Fellowship of the Faculty of Forensic and Legal Medicine If you would like to provide any information in confidence, please contact the Registrar of the Faculty.Submitting the form will be taken as equivalent to a traditional signature* I agree to the privacy policy.Submitting the form will be taken as equivalent to a traditional signature
