Application for Admission to Membership – Fellowship

  • Application for Admission to Membership – Fellowship

  • Form No: F168
    Last Revised: January 2024
    Version: v12

  • 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.

  • Personal Details

  • Date of birth*
     - -
  • Are you of Aboriginal or Torres Strait Islander origin?

  • Contact Details

  •  -
  •  -
  •  -

  • Address

  • Mailing address*

  • Qualifications

    Primary Medical Degree already on file.

  • Medical Board Registration Details

  • Other:

  • Continuing Professional Development

    (for those registered to practise in Australia only)

  • Read ACEM's CPD Homes Policy (COR909).

  • Professional Details

  • Workplace 1

  • Are you working in the ED at this workplace?
  • Employment type
  • Start date
     - -

  • Workplace 2

  • Are you working in the ED at this workplace?
  • Employment type
  • Start date
     - -

  • Workplace 3

  • Are you working in the ED at this workplace?
  • Employment type
  • Start date
     - -

  • 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?*
  • 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?*
  • Question 3: Have you been charged or convicted of a criminal offence (other than minor traffic or other trivial offences)?*
  • Question 4: Are you subject to any restriction or limitation under any mental health law or regulation?*
  • 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.

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