Student Affiliate Form Student Affiliate Form Step 1 of 3 33% This form is designed to allow those seeking to join the faculty as student affiliates to provide sufficient information to allow the Membership and Fellowship Committee (MFC) to make an appropriate decision. Information submitted via this form will be used to carry out any reasonable activity related to the administration of the FFLM Membership process and is held subject to relevant data protection legislation. Failure to complete all sections may result in rejection of the application as the Faculty considers this information is essential to enable the MFC to determine whether to recommend to the Board that an individual should be invited to join the Faculty. The MFC will assess the application based on the information within this form. Because of the innate variability of the structure and information contained within Curriculum Vitae (CV) the MFC will not consider them. Please DO NOT insert or attach CVs to this form.Student Affiliates This category is open to full time students enrolled at an accredited university and are studying in a field and at an educational institution related to forensic and legal medicine.All applications are reviewed and assessed by the MFC who may take advice at their discretion. It is a thorough but confidential process based on submitted information only and which does not involve the candidates directly. Following a decision by the MFC, representative of the MFC will write / email the applicant to inform them of the outcome. This outcome may include recommending that an applicant is more suited to an alternative membership group than that applied for. If the outcome is unfavourable the applicant may apply again. Please note – unsuccessful applicants are not automatically reviewed by the Faculty and so the onus is strictly on an applicant to submit a new application form if they wish to be re-considered by the MFC. Applications will be considered at the next appropriate meeting of the MFC. The closing dates for completed applications and the dates of the MFC meetings are available on the website.* I have read & understand the above text (tick to confirm and continue) * Please tick this box to confirm that you have read, understood and accepted our privacy policy Applicant DetailsName* DrMissMrMrsMsProf.Rev. Prefix First Last Date of Birth* DD slash MM slash YYYY Email* (please use your university email address)Address for Confidential Correspondence* Street Address Address Line 2 City County Postcode 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 Country Course of StudyUniversity or other higher educational institution*Course Title*Date Course Commenced DD slash MM slash YYYY Anticipated Month & Year of Completion* DD slash MM slash YYYY Exact day not required.Degree/Diploma course leads to:*Previous work in law or forensic or legal medicine:Membership or affiliation with other medical royal colleges or faculties:Work in forensic or legal medicine aspired to: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 I also give permission for the Faculty to perform checks with my university/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. Untitled* 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. DeclarationI 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 university/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. Consent I agree to the declarations and to the privacy policy.CAPTCHA
