About you
Name Prefix *
- Select - Dr Prof Mr Mrs Miss Ms Air Commodore Air Vice-Marshal Baroness Brigadier Colonel Dame Group Captain Lieutenant Colonel Major General Prof Colonel Prof Dame Prof Sir Sir Surgeon Captain Surgeon Commander Surgeon Commodore Wing Commander Mx Air Marshall Surgeon Vice Admiral Vice Admiral Sister Lord Nurse
First Name *
Last Name *
Phone Number *
Email *
Street Address *
Street Address Line 2
City *
Postal Code *
Country *
United Kingdom Afghanistan Åland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo, Republic Of The Congo, The Democratic Republic of the Cook Islands Costa Rica Côte d’Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic of Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Macedonia Northern Mariana Islands Norway Oman Pakistan Palau Palestine, State of Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe
Job Title *
Medical career stage *
- Select - Medical student Dental student Foundation year 1 or 2 Doctor in training Consultant (CCT/CESR) GP Dentist in Primary Care Dentist in secondary-care Medical Manager Other Pharmacy student Retired Staff and associate specialist doctor
Medical career stage - other
Non medical career stage
- None - Clinical scientist Trainee public health specialist Qualified public health specialist Other
Non medical career stage - other
Doctor in training grade
- None - Foundation Year 2 Core/Specialty Trainee 1 Core/Specialty Trainee 2 Core/Specialty Trainee 3 Specialty Trainee 4 Specialty Trainee 5 Specialty Trainee 6 Specialty Trainee 7 Other
Doctor in training grade (other)
Specialty *
- Select - Acute Internal Medicine Allergy Anaesthetics Audiological Medicine Audio Vestibular Medicine Cardiology Cardiothoracic Surgery Chemical Pathology Child and Adolescent Psychiatry Clinical Genetics Clinical Immunology Clinical Neurophysiology Clinical Oncology Clinical Pharmacology and Therapeutics Clinical Radiology Community Sexual & Reproductive Health Dental Surgery Dermatology Diagnostic Neuropathology Emergency Medicine Endocrinology and Diabetes Mellitus Forensic Histopathology Forensic Psychiatry Gastroenterology General (Internal) Medicine General Practice General Psychiatry General Surgery Genito-urinary Medicine Geriatric Medicine Haematology Histopathology Immunology Infectious Diseases Intensive Care Medicine Medical Microbiology Medical Microbiology and Virology Medical Oncology Medical Ophthalmology Medical Psychotherapy Medical Virology Neurology Neurosurgery Not applicable Nuclear Medicine Obstetrics and Gynaecology Occupational Medicine Old Age Psychiatry Ophthalmology Oral and Maxillofacial Surgery Other Otolaryngology Paediatric and Perinatal Pathology Paediatric Cardiology Paediatric Emergency Medicine Paediatrics Paediatric Surgery Palliative Medicine Pharmaceutical Medicine Plastic Surgery Psychiatry Psychiatry of Learning Disability Psychotherapy Public Health Medicine Rehabilitation Medicine Renal Medicine Respiratory Medicine Rheumatology Sport and Exercise Medicine Stroke Medicine Trauma and Orthopaedic Surgery Tropical Medicine Urology Vascular Surgery
Geographical region *
- Select - England - East of England England - London England - Midlands England - North East & Yorkshire England - North West England - South West England - South East Northern Ireland Scotland Wales Overseas Other Armed Forces
Registration status
Do you continue to hold a licence to practice with the GMC/GDC? *
- Select - Yes No
If Retired: Were you in ‘good standing’ with the GMC/GDC at the point of retirement?
- None - Yes No
Have you been subject to any organisational disciplinary procedure, formal or otherwise within the last five years?? *
- Select - Yes No
Have you been subject to a criminal conviction or caution whether successful or unsuccessful within the last five years? *
- Select - Yes No
Have you been subject to any formal investigations or decisions (including restrictions, suspensions or licence revoked) overseen by the GMC or GDC within the past five years? *
- Select - Yes No
Professional activities within the last five years This section relates to activities undertaken during the last five years since you have held fellowship of FMLM
Any gaps in annual appraisal within the past five years *
- Select - Yes No
Do you continue to meet the required level of continuous professional development for your role? *
- Select - Yes No
How much of your practice is undertaken in the UK? *
- Select - I only practise in the UK Most of my practice is in the UK Most of my practice is outside the UK I only practice outside the UK
On average, what percentage of your role is leadership and management (non-clinical)? *
Associate Fellows/Fellows ONLY - Are you considering applying to Fellowship/Senior Fellowship in the next 12 months?
- None - Yes No
Declaration