Application form for FREE Student and Foundation Membership of the Royal College of Physicians of Edinburgh

**Fields marked * are mandatory**
Title:*
Sex:*
Date of Birth:*	Day: Month: Year:
Surname/Family Name:*
Forenames/Given names:*
Home Address:*
Professional or College address:
Preferred e-mail Address:*
Alternative Email Address:
An e-mail will be sent to your preferred e-mail address confirming your acceptance as a Student and Foundation Member. If you do not receive this please contact a.burnett@rcpe.ac.uk. It is important that you type your e-mail address accurately.
Are you a:*
What university did you train at/are you training at: *
Month: Year: On what date did you, or do you expect to, complete your primary medical qualification? Please state month and year:*
How did you hear about Student and Foundation Membership of the RCPE? *
We require proof of status that you are a bona fide doctor, physician assistant or medical student. UK doctors are asked to provide their GMC number. If you do not have a GMC number, please provide the name and address/email of someone who can be contacted to act as a referee. Medical Students may use a tutor or Faculty secretary, physicians assistants should give the details of a departmental colleague, doctors should give the details of a senior colleague.
My proof of status is:*
GMC Number:
Referee:
GMC No:
OR referee:
Title:
Surname/Family Name:
Forenames/Given names:
Institution (ie Hospital/University):
Professional or College address:
Preferred e-mail Address:

DECLARATION OF INTERESTS

Have you, at any time, had any criminal convictions, or do you have any criminal convictions pending?*	Yes
	No

If you answered ‘yes’, please provide further information:

Have you at any time had (or do you have pending) any suspensions, limitations or removal of medical registration?*	Yes
	No

If you answered ‘yes’, please provide further information:

Do you have any health problem likely to adversely affect your professional work?*	Yes
	No

If you answered ‘yes’, please provide further information:

Thank you for your application