Please complete this FCI Membership form in full.

When completing the personal details and permission section of the application, when prompted, please tick ‘Yes’ if you are happy to give your permission and ‘No’, if not. Your details will not be shared with any individuals or organisations without prior consent, in accordance with GDPR.

All personal 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.

For questions 14, 15 and 16 please ensure you provide dates wherever possible and avoid using acronyms unless the organisation is very well known (e.g. NHS). Refrain from using URLs and or links to social media accounts.  Full guidelines regarding criteria and how to fill in your application (including example answers) can be found on our website. 

If you require assistance in completing the form, please email info@fci.org.uk.

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* 1. Personal details and Permissions.


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* 2. Current job role(s)

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* 3. Organisation(s)

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* 4. Profession

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* 5. Professional registration body name

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* 6. Professional registration number

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* 7. Please attach scanned copies of documents that confirm both your professional registration and qualifications

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
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* 8. If needed, please upload any further documents

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
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* 9. Are you a current Member/Associate of the FCI?

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* 10. Organistational Memberships (e.g. MRCGP, BCS etc.)

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* 11. If approved for FCI membership, are you happy for your name to be shared on the Faculty website?

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* 12. If approved for FCI membership, are you happy for your details (name, profession, employer/role and membership of other organisations) to be included in a directory that can shared with other members? (This would not be available to non-members.)

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* 13. Areas of Interest e.g. AI, Genomics, Personalised Care, Language and Terminology

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

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* 15. 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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* 16. 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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* 17. 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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* 18. Signed :

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* 19. Date:

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