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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
Forenames: Gender:
Tel: Tel:
Fax: Fax:
E-mail: E-mail:
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:
Number:
QUALIFICATIONS
Signature…………………………………………………………………Date………………………….
CHECKLIST
Completed Form
If you are not registered with the UK GMC you must also ensure that you
enclose your original primary medical certificate for verification
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.
Information given by you on this application form will be shared as necessary with Faculty
staff, officers and examiners.