Personal and professional information

Welcome to the new version of the FFLM Examinations application form.

Please provide us with as much information as possible so we can easily identify you and your choices. If a question does not apply to you, please skip it, if you can. Questions with an asterisk require an answer. Otherwise enter Non applicable (or simply NA) in the answer field.

Kindly note that we may contact you by email to ask for supporting evidence. By completing this form and sending it to us you automatically certify that all the information you have entered is true, complete and accurate.

Once we have received both this form and your payment, should you be eligible for the examination you have applied for, you will be entered for that examination session and notified by email accordingly, after the application closing date.

Should you have any queries about this form please email us:

* 1. What is your title?

* 2. What is your first name?

* 3. What is your surname?

* 4. Do you have any former name (before Deed Poll change, single or maiden name) or any name you are also known as?

* 5. What is your email address? A personal email address, rather than a work one, is preferable.

* 6. What is your postal address?

* 7. What is your preferred contact telephone number?

* 8. What is your date of birth (DD/MM/YYYY)?

* 9. What is your gender?

* 10. What is your current post?

* 11. What is your specialty?

* 12. Who is your employer? If self employed please let us know below.

* 13. What is your GMC/NMC registration (or equivalent body) number (if relevant)?

* 14. What is its category (if relevant)?

* 15. When was it obtained (if relevant)?

* 16. Regarding your primary qualification, what is your degree (MD, MBBS etc)?

* 17. When was it conferred?

* 18. What was the issuing university?

* 19. Which college/faculty/school?

* 20. Where (city and country)?