Application for Admission to Membership

Application for Admission to Membership – Fellowship
Form No: TA168
Last Revised: January 2024
Version: v12
Name*

Given name(s)Last Name
ACEM ID*
Name for inscription on Membership Certificate*
College Pledge
As a condition of Fellowship of the Australasian College for Emergency Medicine, I hereby pledge to conduct myself in accordance with the College’s Core Values of Respect, Integrity, Equity and Collaboration and its governing Constitution, Regulations, Code of Conduct and associated documents.

In my work and conduct as a specialist emergency physician, I will uphold the ethical and professional standards expected of a Fellow of the College and as a member of the medical profession.
Signature*

Clear

Personal Details
Name*

TitleFirst NameMiddle NameLast Name
Preferred name
Date of birth*

DayMonthYear
Date
Are you of Aboriginal or Torres Strait Islander origin?

AboriginalTorres Strait Islander
Are you descended from Māori? (that is, did you have a Māori birth parent, grandparent or great-grandparent, etc.)

Yes
Are you of Pacific Peoples origin?

Yes
Contact Details
Phone*

Area CodePhone Number
Mobile

Area CodePhone Number
Alternate phone

Area CodePhone Number
Email*
example@example.com
Other email
example@example.com
Fax
Address
Residential*

Street Address

Street Address Line 2

CityState / Province

PostcodeCountry
Mailing address*

As aboveOther
Mailing*

Street Address

Street Address Line 2

CityState / Province

PostcodeCountry

Qualifications

Primary Medical Degree already on file.
Other degree
University
Country
Year conferred
Other specialist college traineeships
Other specialist college fellowships
Medical Board Registration Details
Ahpra registration number
MCNZ registration number
Other:
Country
Authority name
Registration number
Continuing Professional Development

(for those registered to practise in Australia only)
I am choosing NOT to participate in the ACEM CPD Program as part of my College membership.
I have advised the Australian Health Practitioner Regulation Agency (Ahpra) that my alternate CPD Home is (please select from drop list below):*
I understand that as part of ACEM membership requirements, I will have to provide evidence of compliance with my alternate CPD Home on an annual basis pursuant to the CPD Homes Policy (COR909).*

I understand
Read ACEM's CPD Homes Policy (COR909).

Declaration
Question 1: Pursuant to the ACEM Constitution and associated regulations, all Fellows are required to hold current medical registration. Do you have any suspension, condition, reprimand, restriction or undertaking, other than those routinely associated with your category of registration, imposed on you by a regulatory authority that affects or limits your having unconditional medical registration in Australia, New Zealand or any other country where you reside or practise?*

YesNo
Please provide details:
Question 2: If you answered ‘NO’ to Question 1 above, are you aware of any complaint or other action that may potentially alter your answer to that question?*

YesNo
Please provide details:
Question 3: Have you been charged or convicted of a criminal offence (other than minor traffic or other trivial offences)?*

YesNo
Please provide details:
Question 4: Are you subject to any restriction or limitation under any mental health law or regulation?*

YesNo
Please provide details
I declare that the answers to the four (4) questions given above have been completed by me, are true and correct, and I undertake to advise the Chief Executive Officer of the College immediately should circumstances arise to alter any of the responses given.*

Clear
Date*

DayMonthYear
Date

Annual Subscription Fee
Payment of the appropriate Fellowship annual subscription fee must be paid prior to admission to membership as a Fellow. An invoice will be issued once the application has been deemed eligible. The amount payable is calculated according to the following:
1. the month during which admission to membership as Fellow is anticipated; and
2. the country in which the applicant is residing and working at the time the application is made.
For applicants who have completed all the requirements of the FACEM Training Program, this fee structure consists of:
- a base application fee; and
- pro-rata Fellowship Subscription for the current financial year; less
- a pro-rata refund of annual training fee (where appropriate).
For applicants who have completed all the requirements of the SIMG Pathway, this fee structure consists of:
- a base application fee; and
- a pro-rata Fellowship Subscription for the current financial year.
Further information on fees and payments is available on the Fees and Payments page on the ACEM website.

Note that the subscription fee covers the Fellowship to 30 June. Fees are due annually in July.
Select the option that applies:*

FACEM Training submissionSIMG Pathway submission
Should be Empty:

Application for Admission to Membership – Fellowship