For each answer, please provide dates wherever possible and avoid using acronyms unless the organisation is very well known (e.g. NHS). Full guidelines regarding criteria and how to fill in your application (including example answers) can be found on our website.

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* 1. These details will be removed from your application before it is sent to the assessment panel. Your application will be anonymous, but could be identifiable via any specific experiences you describe or reference to publications that you provide.

Please let us know your title, name, contact email and telephone number

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* 2. Degrees and other relevant qualifications

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* 3. Professional registration body 

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* 4. Professional registration number

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* 5. Current role(s)

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* 6. Previous roles

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* 7. Are you currently enrolled on the NSHCS/HEE Scientist Training Programme or Higher Specialist Scientist Training Programme?

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* 8. Please describe your clinical informatics experience in the workplace (including start and finish dates). [recommended maximum of 500 words]

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* 9. Please provide details of your leadership roles and/or recognition in the field of clinical informatics at a local, national, and international level. [recommended maximum of 500 words]

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* 10. Please describe your commitment to the advancement of clinical informatics as a professional discipline. This should include details of contributions that you have made both in your main role and/or any other projects you have worked on. [recommended maximum of 500 words]

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* 11. Declaration: I understand that if elected as a Member or Fellow I will be required to contribute an annual fee to the Faculty of Clinical Informatics. This is currently set at £102 per annum for Membership and £255 per annum for Fellowship. Other pricing options are available based on income.

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* 12. Signed :

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* 13. Date:

Date
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