Application for Admission to Membership

Application for Admission to Membership – Educational Affiliate

The ACEM Board may admit as Educational Affiliates, medical practitioners registered to practise in Australia or New Zealand (as applicable).
Form No: F736
Last Revised: January 2024
Version: v4
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 a medical 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*

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

Postal / Zip CodeCountry

Medical Board Registration Details
Ahpra registration number
MCNZ 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
Workplace Details
Workplace name*
Location*
Are you working in the ED at this workplace?*

YesNo

Declaration
Question 1: Pursuant to the ACEM Constitution and associated regulations, all Educational 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.*
Date*

DayMonthYear
Date

Application for Admission to Membership – Educational Affiliate