TEST – Membership TEST - Member application form 12Applicant Details3Declarations InstagramThis 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 Email* Phone*Date of Birth* Please select the most appropriate*Please selectDoctorNurse/MidwifeParamedicPharmacistOpticianStudentDentistLawyer/Barrister/Solicitor/Coroner/Coroner OfficerProfessor/AcademicScientistVeterinaryWhich area do you work in*Please selectForensic PsychiatristForensic OdontologistMedical CoronerForensic PathologistLegally Qualified Coroner/Procurator Fiscal/Procurator Fiscal Depute in ScotlandMembership applied for*Please selectMember by Equivalent Qualification British IslesMember by Equivalent Qualification OverseasHave you previously passed an FFLM exam?*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* Do you reside*Please selectBritish Isles and IrelandOverseasMembership applied for*Please selectLicentiate GFM British IslesLicentiate SOM British IslesLicentiate SOM (c) British IslesMember by Examination GFM British IslesMember by Examination DLA British IslesMember by Examination MLA British IslesMember by Examination SOM British IslesNurse / Midwife Affiliate British IslesMembership applied for*Please selectNurse / Midwife Affiliate British IslesMembership applied for*Please selectNurse / Midwife Affiliate OverseasCategory applied for*Please selectForensic PractitionerMiscellaneousSDSProfessional Registration Body (e.g. GMC, GDC, NMC, HCPC)*Please selectNMCOtherPlease list other below*Website to confirm professional registration* Professional Registration Number (e.g. GMC, GDC, NMC, HCPC)*Date Joined Registered Body* Area of Interest - (Forums to be added)* Doctor Profession* 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 Fellowships/Memberships of other colleges or societies*Honours, Degrees or Qualifications where relevant (including date awarded)*Please add Qualification, Awarding Body and Date awardedHave you attended a CED or GFM training course*Please selectYesNoIf yesPlease selectConducted Energy Device HCP Assessment Training CourseFFLM Introductory Course in General Forensic MedicineDate of the course* Membership 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) RetiredCategory applied for*Please selectForensic PractitionerMedico-Legal AdviserDento Legal AdviserMiscellaneousMedically qualified CoronerMedical Examiner/Medical ReviewerSDSVeterinary ClinicianExpert WitnessProfessional Registration Body (e.g. GMC, GDC, NMC, HCPC)*Please selectGMCGDCNMCHCPCOtherRole 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 Please name the otherDeclarationPlease 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*
