Membership application form

Membership (MFPM) application form

For PMST holders and trainees only
Personal details
Full name (as recorded on the medical register)*

Title (Dr etc)First nameMiddle name(s)Last name
Known as (if applicable)
Let us know if your preferred first and/or last name are different to the above and we will use these in communications with you.
FPM membership number (if known)
GMC registration number*
Main email address (required)*
Alternative email address (optional)
Eligibility

As a PMST holder or PMST trainee, you are eligible for Membership (MFPM) when you pass FPM's Diploma in Pharmaceutical Medicine (DPM).
When did you pass the DPM exam?
(DD/MM/YYYY)
Declaration

I would like to apply for Membership of the Faculty of Pharmaceutical Medicine (FPM) as indicated, and declare that the information given on this form is true to the best of my belief and knowledge. I hereby consent to being admitted to membership of FPM and faithfully promise to abide by FPM's Articles of Association and Regulations and the Laws, Bye-Laws, Statutes and Regulations of the Parent Colleges as they apply to members of the Faculty of Pharmaceutical Medicine.
Signature of applicant (use the cursor to sign your name)*

Clear
Data protection

The Data Protection Act requires organisations or agencies collecting personal data on individuals to gain their consent before collecting, storing, publishing or analysing their data. By completing and signing this application for membership of FPM you are giving your consent for your data to be stored and used by FPM. All data will be treated with the strictest confidence and will only be used for legitimate FPM purposes, see our Privacy Policy.
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Membership (MFPM) application form

Declaration