Declaration concerning retirement from practice as a specialist emergency physician

Declaration concerning retirement from practice as a specialist emergency physician

Retirement form
Form No: COR459
Last Revised: February 2025
Version: v5
Full name*
ACEM ID*
Residential address*
Primary email address*
example@example.com
Date of retirement*

DayMonthYear
Date
Medical Registration
Will you be registered to practice in Australia as a medical practitioner?*
As an ACEM Retired Fellow who is still registered to practise in Australia, you can now choose to nominate the ACEM CPD Program as your CPD Home, to meet your Ahpra standards for registration.
Where will you be completing your CPD requirements?*

I am choosing to continue my enrolment in the ACEM CPD Program and understand I will be required to complete the annual requirements of the non-FACEM CPD Program pursuant to the ACEM Continuing Professional Development Participation Policy (CPD219). I understand an annual CPD fee will also be payable.I have an alternate CPD Home.
Read ACEM’s Continuing Professional Development Participation Policy (CPD219). ACEM’s fees and payments.
Retirement Declaration

Pursuant to the provisions of the Constitution of the Australasian College for Emergency Medicine (ACEM; the College), I do solemnly and sincerely declare that I have completely and permanently retired from practice, including related activities such as teaching and examining, as a specialist emergency physician and wish to be recognised by the College as a Retired Fellow.

I confirm that I have ceased to act as an expert witness in the field of emergency medicine, except in:
- cases for which I have already provided an opinion prior to the date of signing this Retirement Declaration; and
- cases which deal with medical practices current during any time I was in active practice as a specialist emergency physician and prior to my signing this Retirement Declaration.
Reinstatement to Active Fellowship

Should I at any time wish to resume clinical practice as a specialist emergency physician (or undertake any specialist work in emergency medicine) and be reinstated as an active Fellow, I undertake to notify the College in writing forthwith and submit a Reinstatement to Fellowship application. I understand that such application may be subject to an application assessment fee and a reinstatement to membership fee, as published on the ACEM website.

I acknowledge that reinstatement to active Fellowship will be at the discretion of the ACEM Board and that I will be required to satisfy the requirements of the ACEM Continuing Professional Development Program and such other conditions as are deemed appropriate by the ACEM Board. I understand that such conditions may include the requirement to undertake a re-entry to practice program, payment of a further membership fee, and/or payment of any arrears.
Member signature*

Clear
Declared on this day of year
Continuing Professional Development

(for those registered to practise in Australia only)
I am choosing to continue my enrolment in the ACEM CPD Program and understand I will be required to complete the annual requirements of the non-FACEM CPD Program pursuant to the ACEM Continuing Professional Development Participation Policy (CPD219). I understand an annual fee of $100 will be payable.

I understand
Should be Empty:

Declaration concerning retirement from practice as a specialist emergency physician

Medical Registration

Retirement Declaration

Reinstatement to Active Fellowship

Continuing Professional Development