Referee Form: Foundation Membership/Fellowship - Clinicians Working in Secure and Detained Settings (SDS)

Applicant Details(Required)

Prefix First Last

Application for Membership or Fellowship?(Required)

Fellowship

Membership

Referee Details

Referee Name(Required)

Prefix First Last

Referee's Professional Registration Body(Required)

Referee's Professional Registration Number(Required)

Referee Email(Required)

Referee Daytime Phone Number(Required)

Referee Professional Address(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

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Supporting Statement

Please provide a brief statement in support of the information cited in the nominees application form. Please give details of your relationship with the candidate and your perceptions of his or her working style, achievements, and commitments. (max 6000 characters)

Referee Declarations

If you would like to provide any information in confidence, please contact the Registrar of the Faculty. (registrar@fflm.ac.uk)

I have reviewed the information provided in support of the candidate’s application and attest to the accuracy thereof(Required)

Yes

No

I am willing to be contacted by the Faculty of Forensic & Legal Medicine to discuss any part of this application.

I note the Criteria for election to Foundation Status of the Faculty of Forensic & Legal Medicine is:

Foundation Membership requires at least 3 years experience of the specialty AND possession of a relevant qualification.

Foundation Fellowship requires at least 5 years experience of the specialty AND possession of a relevant qualification AND ALSO evidence of having made a significant contribution to the specialty.

All applicants must be a registered dental (or medical) practitioner, up to date with appraisals & revalidation, make a declaration concerning complaints, obtain two satisfactory references to confirm qualifications, employment and if necessary, achievements.

I know of no reason why the candidate should not be considered for Foundation Membership / Fellowship of the Faculty of Forensic and Legal Medicine.

Referee Form Foundation Membership/Fellowship for Clinicians Working in Secure & Detained Settings

Referee Details

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Referee Declarations