Associate (Trainee) Membership and PMST Application Form

Associate (Trainee) Membership and Pharmaceutical Medicine Specialty Training Application Form
1. Personal Details
Your name*

TitleFirst NameLast Name (as registered with the GMC)
Your primary correspondence address*
Your primary telephone number*
Your primary email address*
example@example.com
Country of citizenship*
Date of birth*

DayMonthYear
Date
Gender*

FemaleMalePrefer not to say

2. Existing membership of FPM
Are you an existing member of the Faculty of Pharmaceutical Medicine (FPM)?*

YesNo
What class of FPM membership do you hold?

Fellow (FFPM)Member (MFPM)AffiliateDon't know
Please enter your FPM membership number

3. Registration and licence to practise
GMC registration number*
Date of full GMC registration*

DayMonthYear
Date
Are you GMC registered with a licence to practise?*

YesNo
Do you hold medical registration in another country?*

YesNo
Enter name of country
Enter name of registration body
Enter registration number
Date of registration

DayMonthYear
Date

4. Diploma in Pharmaceutical Medicine
Have you passed FPM's Diploma in Pharmaceutical Medicine exam?*

YesNo
If you answered "Yes", please enter the year you passed the exam
Enter as yyyy

5. Degrees and diplomas - primary and specialist medical qualifications
In chronological order starting with the earliest qualification, please enter your primary and postgraduate medical qualifications.

If you were awarded a medical royal college qualification (e.g. MRCP), you must upload a copy of either the pass letter or certificate to your application.
Qualification 1 title *
Qualification 1 awarding body/country*
Date qualification 1 awarded*
Enter as mm/yyyy
Upload copy of qualification 1*

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Qualification 2 title
Qualification 2 awarding body/country
Date qualification 2 awarded
Enter as mm/yyyy
Upload copy of qualification 2

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Qualification 3 title
Qualification 3 awarding body/country
Date qualification 3 awarded
Enter as mm/yyyy
Upload copy of qualification 3

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Qualification 4 title
Qualification 4 awarding body/country
Date qualification 4 awarded
Enter as mm/yyyy
Upload copy of qualification 4

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Qualification 5 title
Qualification 5 awarding body/country
Date of qualification 5 awarded
Enter as mm/yyyy
Upload copy of qualification 5

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6. Previous enrolment on the PMST programme
Have you ever been enrolled on the PMST programme?*

YesNo
Why did you leave the PMST programme?

I resigned from the programmeI was removed/released from the programme

7. Enrolment on other specialty training programmes
Do you hold a current national training number (NTN) in another specialty*

YesNo
Please enter your current NTN.
Please enter the full name and address of your deanery or HEE local office.
Are you on the GMC specialist register?*

YesNo
What is/are your specialties?
Are you on the GMC's GP register?*

YesNo

9. Your Educational Supervisor
Name of your prospective educational supervisor*

TitleFirst NameLast Name (as registered with the GMC)
Your prospective educational supervisor's contact details including email address*
Is your educational supervisor formally recognised by the Pharmaceutical Medicine Deanery to perform the role?*

YesNo

10. Conditions of Enrolment on to PMST
On being enrolled on to the PMST programme in the Pharmaceutical Medicine Deanery, I agree to meet the following conditions throughout the duration of the programme to:

i) always have at the forefront of my medical and professional practice the principles of Good Medical Practice (2013) for the benefit of safe patient care. Trainees should be aware that Good Medical Practice requires doctors to keep their knowledge and skills up to date throughout their working life, and to regularly take part in educational activities that maintain and further develop their competence and performance;

ii) ensure that the care I give to patients is responsive to their needs, that it is equitable, respects human rights, challenges discrimination, promotes equality, and maintains the dignity of patients and carers;

iii) participate in workplace-based appraisal as well as educational appraisal, and acknowledge and agree to the need to share information about my performance as a doctor in training with other employers involved in my training and with the postgraduate dean on a regular basis;

iv) maintain regular contact with the deanery and FPM by responding promptly to communications from them, usually through email correspondence; for example, this will include keeping the deanery and FPM appraised of any change of job, contact details, requests for time out of programme;

v) maintain my GMC registration with a licence to practise and my membership of FPM, knowing that failure to maintain my medical registration and FPM membership can lead to my removal from the PMST programme;

vi) participate proactively in the appraisal, assessment and programme-planning process, including providing documentation which will be required to the prescribed timescales;

vii) engage fully with the revalidation process by attending ARCP when requested to do so, and to produce all supporting information necessary for the postgraduate dean to make a recommendation to the GMC as to my fitness to practise;

viii) ensure that I develop and keep up to date my learning portfolio which underpins the training process and documents my progress through the programme;

ix) use training resources available optimally to develop my competences to the standards set by the specialty curriculum; and

x) support the development and evaluation of this training programme by participating actively in the national annual GMC/COPMeD trainee survey and any other activities that contribute to the quality improvement of training.

I acknowledge the importance of these responsibilities. If I fail to meet them I understand that the postgraduate dean may require me to meet with them to discuss why I have failed to comply with these conditions.
Applicant's signature*

Clear
Applicant's name*

First NameLast Name (as registered with the GMC)
Date signed*

DayMonthYear
Date

11. Declaration - Associate (Trainee) Membership and PMST enrolment
"I would like to apply for Associate (Trainee) membership of FPM, and to enrolment on to the PMST programme as indicated and declare that the information given on this form is true to the best of my belief and knowledge. I consent to being admitted to Associate (Trainee) membership of FPM and faithfully promise to abide by the articles of association of FPM and the laws, byelaws, statutes and regulations of the Royal Colleges of Physicians as they apply to members of FPM, and the conditions of enrolment on to PMST as specified in section 10."
UK data protection legislation 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.
Applicant's signature*

Clear
Applicant's name*

First NameLast Name (as registered with the GMC)
Date signed*

DayMonthYear
Date

12. The General Data Protection Regulation
In order to comply with the General Data Protection Regulation (GDPR), it is essential that we have your permission to use personal data held on you, for the purpose of FPM and the Joint Royal Colleges of Physicians Training Board carrying out any reasonable activity for the efficient administration of its statutory obligations with regard to specialist registration and certification, and membership of FPM. These data will only be disclosed, as part of the process of administering your training programme or application for registration, with (as appropriate):
- the relevant regional and national training bodies;
- the postgraduate medical deans and their staffs;
- relevant royal college and FPM officers, representatives and staff;
- Educational Supervisors, FPM Specialty Advisers;
- the GMC;
- specialist and trainee societies and organisations; and
- employing organisations.
"I give permission for my personal data to be made available to third parties as required for the purposes of monitoring, assessing and certifying my specialist training as per section 12 on the General Personal Data Regulation (GDPR)."
Applicant's signature*

Clear
Applicant's name*

First NameLast Name
Date signed*

DayMonthYear
Date
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Associate (Trainee) Membership and Pharmaceutical Medicine Specialty Training Application Form