Application Form Member application form 12Applicant Details3Declarations FacebookThis field is for validation purposes and should be left unchanged.Please select to confirm:* I have read and understand the above text (tick to confirm and continue) Please enter your name in the correct format, using standard capitalisation (e.g., John Smith), rather than all upper or all lower-case letters Applicant DetailsName* Dr.Miss.Mr.Mrs.Ms.Prof.Rev. Title First Last Date of Birth* Email* Phone*Category applied for*Please selectForensic PractitionerMedico-Legal AdviserDento Legal AdviserMiscellaneousMedically qualified CoronerMedical Examiner/Medical ReviewerSDSVeterinary ClinicianExpert WitnessMembership applied for*Please selectAffiliate British IslesAffiliate OverseasAssociate British IslesAssociate OverseasFellow (GMC/GDC licence relinquished) RetiredFellow OverseasFellow RetiredLicentiate GFM British IslesLicentiate GFM OverseasLicentiate SOM British IslesLicentiate SOM OverseasLicentiate SOM (c) British IslesLicentiate SOM (C) OverseasMember (GMC/GDC licence relinquished) RetiredMember by Equivalent Qualification British IslesMember by Equivalent Qualification OverseasMember by Examination GFM British IslesMember by Examination GFM OverseasMember by Examination DLA British IslesMember by Examination DLA OverseasMember by Examination MLA British IslesMember by Examination MLA OverseasMember by Examination SOM British IslesMember by Examination SOM OverseasMember RetiredNurse / Midwife Affiliate British IslesNurse / Midwife Affiliate OverseasParamedic Affiliate British IslesParamedic Affiliate OverseasPharmacy Affiliate British IslesPharmacy Affiliate OverseasPharmacy Affiliate OverseasOptician Affiliate British IslesOptician Affiliate OverseasLifetime LicentiateLifetime MembershipLifetime FellowshipLicentiate (NMC Licence relinquished) RetiredProfessional Registration Body (e.g. GMC, GDC, NMC, HCPC)*Professional Registration Number (e.g. GMC, GDC, NMC, HCPC)Website to confirm professional registration Date Joined Registered Body Area of Practice*Please selectClinical Forensic Medicine Including Sexual OffencesMedico Legal AdvisorDento Legal AdvisorLegal PracticeAcademicForensic PsychiatryCoronerMedical Examiner/ReviewerTribunal MemberForensic OdontologistAnatomical Pathology TechnicianSecure & Detained SettingsOtherVeterinaryProfession* Doctor Nurse/Midwife Paramedic Legal Adviser Lawyer/Barrister/Solicitor/Coroner/Coroner Officer Scientist Student Veterinary Professor/Academic Pharmacist Other Other (please specify)*Address for Confidential Correspondence* Street Address Address Line 2 City County Postcode Where did you hear about us* Linkedln Facebook Faculty Files Word of Mouth The FFLM Website 10times Bluesky Other Please name the otherFellowships/Memberships of other colleges or societies*Honours, Degrees or Qualifications where relevant (including date awarded)*Please add Qualification, Awarding Body and Date awardedHave you previously passed an FFLM qualification?*Please selectYesNoIf yes, which one/s:Please selectDiploma of Legal MedicineMFFLM (Dento-legal Medicine) Part 1MFFLM (General Forensic Medicine) Part 1MFFLM (Medico-legal Medicine) Part 1MFFLM (Sexual Offence Medicine) Part 1LFFLM (General Forensic Medicine) Part 1LFFLM (Sexual Offence Medicine) Part 1MFFLM (Dento-legal Medicine) Part 2MFFLM (General Forensic Medicine) Part 2MFFLM (Medico-legal Medicine) Part 2MFFLM (Sexual Offence Medicine) Part 2LFFLM (General Forensic Medicine) Part 2LFFLM (Sexual Offence Medicine) Part 2LFFLM (SOM)[c] for experienced clinicians via Prescribed/Equivalent ExperienceDate of Exam Have you attended a CED or GFM training course*Please selectYesNoIf yesConducted Energy Device HCP Assessment Training CourseFFLM Introductory Course in General Forensic MedicineDate of the course* Role 1Title*Employer*Date started* Average Hours Per Week*Role 2TitleEmployerDate started Average Hours Per WeekRole 3TitleEmployerDate started Average Hours Per Week Reason for application*Please provide a very brief outline of your reasons for wishing to join the FFLM (no more than 1800 characters) Additional informationE.g. record here that you have passed the MFFLM, LFFLM, DLM or DipHFID examination. (no more than 1500 characters)Where did you hear about this event Linkedln Facebook Bulletin Word of Mouth Website 10times DeclarationPlease tick to confirm you have read and accepted the form of faith* I have read and accepted the Form of Faith 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:Complaint Declaration* 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. Complaint Details*If this situation should change before the date of the MFC, I undertake to inform the Faculty promptly in writingDeclarationI 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. * I hereby give my explicit consent to the processing of my personal data in accordance with the Data Protection Act 2018 and the FFLM Privacy Policy.Date*
