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

Application for Admission to Membership – International Affiliate (Developing Country)
Form No: COR565
Last Revised: January 2024
Version: v5
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

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).

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)

Declaration
Question 1: Pursuant to the ACEM Constitution and associated regulations, all International Affiliates 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
Should be Empty:

College Pledge