Application for Admission to Membership – International Affiliate (Developing Country)

Application for Admission to Membership – International Affiliate (Developing Country)
Form No: F565
Last Revised: September 2025
Version: v6
In order to apply for International Affiliate membership of the Australasian College of Emergency Medicine (ACEM, the College) the medical practitioner must:
- Hold a Master of Medicine degree in Emergency Medicine (EM) or equivalent degree from an university in a developing country (as defined by the College); and
- Be living in a Developing Country; and
- Be working in a Developing Country in the field of EM.
Membership as an International Affiliate cannot be awarded to a Fellow of the College or to a person holding any other level of membership of the College.
Name*

Given name(s)Last Name
ACEM ID
Name for inscription on Membership Certificate*
College Pledge
As a condition of membership 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 an emergency medicine practitioner, I will uphold the ethical and professional standards expected of a member 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

Postal / Zip Country
Mailing address*

As aboveOther
Mailing*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Qualifications
Primary Medical Degree*
University*
Country*
Year conferred*
Masters Medical Degree*
University*
Country*
Year conferred*
Other specialist college traineeships
Other specialist college fellowships

Medical Board Registration Details
Country*
Authority*
Registration number*
Ahpra registration number
MCNZ registration number
Other:
Country
Authority name
Registration number
Continuing Professional Development
International Affiliates are not required to participate in the ACEM CPD Program. However, ACEM offers a modified CPD Program for IAs who wish to opt in. The requirements for the modified ACEM CPD Program are outlined below:
- 50 Annual hours under any of the three (3) CPD Categories (Educational Activities, Reviewing Performance, Measuring Outcomes)
- 4x Different Essential Emergency Medicine (EEM) procedural skills
- Professional Development Plan (PDP) and Reflection
If you wish to enrol in the ACEM CPD Program, please complete the following:

I wish to enrol in the ACEM CPD Program
I acknowledge that, as an IA member enrolled in the ACEM CPD Program I will need to record the following requirements*:
- 50 Annual hours under any of the three (3) CPD Categories (Educational Activities, Reviewing Performance, Measuring Outcomes)
- 4x Different Essential Emergency Medicine (EEM) procedural skills
- Professional Development Plan (PDP) and Reflection
I acknowledge that I will be obligated to record all annual CPD requirements for my enrolled CPD program, into the ACEM CPD Platform by the 31 December annually.

I acknowledge that I will be obligated to participate in the Audit process as outlined by the ACEM CPD Committee, if selected for a CPD compliance audit for the year/s in which I am enrolled in the ACEM CPD program.
I acknowledge that, as an IA member enrolled in the ACEM CPD Program I will need to record the following requirements:
- 50 Annual hours under any of the three (3) CPD Categories (Educational Activities, Reviewing Performance, Measuring Outcomes)
- 4x Different Essential Emergency Medicine (EEM) procedural skills
- Professional Development Plan (PDP) and Reflection
I acknowledge that I will be obligated to record all annual CPD requirements for my enrolled CPD program, into the ACEM CPD Platform by the 31 December annually.
I acknowledge that I will be obligated to participate in the Audit process as outlined by the ACEM CPD Committee, if selected for a CPD compliance audit for the year/s in which I am enrolled in the ACEM CPD program.
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).

Current Employment Reference

Please provide the contact details of your current employer so the College can contact them to verify your employment.
Hospital/Employer name*
Employer contact name*
Contact position*
Contact email*
example@example.com
Contact phone*
FACEM Referee

Please provide the contact details of a Fellow of ACEM (FACEM) that the College can contact to support your application.
Name*

First NameLast Name
Email*
example@example.com
ACEM ID (if known)

Application for Admission to Membership – International Affiliate (Developing Country)

College Pledge

Personal Details

Contact Details

Address

Qualifications

Medical Board Registration Details

Other:

Continuing Professional Development

Current Employment Reference

FACEM Referee

Acknowledgement of Membership Requirements

Declaration