EXAMINATION ENTRY FORM

Examination
Membership (MFOM) - Part 1 - MCQ
Membership (MFOM) – Part 2 ** [ Please read note at end]
Diploma in Occupational Medicine – MCQ component
Diploma in Occupational Medicine - Portfolio & Oral component
Diploma in Aviation Medicine
Diploma in Disability Assessment Medicine – Written
Diploma in Disability Assessment Medicine - Clinical

* Preferred Date: * Preferred Location:

Surname: Date of Birth:

Forenames: Gender:

Business Address: Home Address:

(if different)

Tel: Tel:
Fax: Fax:
E-mail: E-mail:

Preferred mailing address: Home/ Business? (Delete not applicable)

Preferred email address: Home/ Business? (Delete not applicable)

Previous attempts at the examination(s) being applied for (if any)

Date Location Candidate Number (if known)

For Office Use Only

Received: Training Post Number:
Training Course Certificate: Candidate Number:
Fee: Examination Date:
Acknowledged (FOM): Result:
Acknowledged (AD): Feedback:
MEDICAL REGISTRATION

Please state your full UK GMC registration number and date awarded:

If you only have limited registration please detail below (registration no., date, date of passing
PLAB and/or name of UK sponsor):

Candidates who do not have full or limited registration will be required to provide
proof of primary medical certificate acceptable to the Academic Dean. These
candidates must produce the original documents [with a validated translation if
not in English] and complete this box:

Other registering body: Date awarded:

Number:

QUALIFICATIONS

Primary Medical Awarding Body Date Awarded

Qualification:

GENERAL PROFESSIONAL TRAINING

Pre-registration Appointments (overseas candidates should give details of their

internship experience in hospital appointments in the first 12 months after qualifying)
Hospital Title of Post Supervising Dates:
Consultant (from - to)

Subsequent appointments (you may attach a separate sheet or CV if necessary)

Employer Title of post Dates: Full-time or
(from - to) hours/w
eek

Please complete in capital letters and black ink

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 POSTS HELD IN PAST 12 MONTHS incl. any in Occupational Medicine (most current
post first) [NEED COLUMN FOR DATES - FROM/TO]

Employer Title of post Brief description of Full-time or

role (including hours/w
occupational eek
medicine
involved)

POST(S) PREVIOUSLY HELD IN OCCUPATIONAL MEDICINE

Employer Title of post Dates: Full-time or

(from – to) hours/w
eek

Please complete in capital letters and black ink

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APPROPRIATE TRAINING COURSE(S)

Course Title & Institute Dates of Full-time or

(proof of satisfactory completion required) Atten Part-
dance time

Please complete in capital letters and black ink

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I hereby apply to be admitted to the above examination. I declare that the information
provided is complete and accurate and I certify that any journal or portfolio submitted
as part of an examination is my own work and is based on casework undertaken by me.
I understand that if I am successful in the examination, a further fee is required before
the certificate will be awarded. I also understand that the Faculty will retain personal
information on me in accordance with the Faculty’s registration under the Data
Protection Act 1998.

Signature…………………………………………………………………Date………………………….

CHECKLIST

Please enclose the following:

Completed Form

Fee (please check current amount)

Journal/Portfolio (if applicable)

Evidence of satisfactory completion of training course (if applicable)

If you are not registered with the UK GMC you must also ensure that you
enclose your original primary medical certificate for verification

IMPORTANT QUESTIONS FOR YOU TO ANSWER

Do you have a disability that you wish to declare in relation to this examination?
If so, please attach to this application form a paper setting out the nature of your
disability and your request for any adjustments, enclosing any evidence that may
be appropriate.

** If applying for the Membership (MFOM) Part 2 exam, please confirm that your
dissertation has received final approval. YES NO

Please note that a confirmation of receipt will be dispatched within two weeks following the
closing date. If you need acknowledgement sooner, please contact the Examinations Co-
ordinator at the address below.

IMPORTANT - PLEASE READ:

Information given by you on this application form will be shared as necessary with Faculty
staff, officers and examiners.

Please complete and return to:-

The Faculty of Occupational Medicine
6 St Andrews Place, Regent’s Park, LONDON, NW1 4LB
Tel: 0207 317 5890 Fax: 0207 317 5899
Website: www.facoccmed.ac.uk

Please complete in capital letters and black ink

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