Application for Founding Fellowship, RCPA Faculty of Clinical Forensic Medicine - Guide and Checklist
Checklist
a) Application Form
For office use only
b) Signature of Nominating RCPA College Fellow (FRCPA)
c) Certified (see below) copies of Qualifications.
d) Payment details

Certified copies of the original certificates must be presented. Please do not send originals as the College
cannot be held responsible for the custody or return of documents.

Certification must be by a Justice of the Peace or registered legal practitioner. Overseas applicants must
have their copies certified by a Justice of the Peace or Commissioner for Oaths.

Please ensure you have completed all relevant information required; incomplete applications will not be
processed. Faxed applications will not be accepted.

Please note that the deadline for this round of applications is COB on Friday 16 October 2015

Your application will be acknowledged by email within 7 days of receipt
Please mail Applications in confidence to:
Chair, First Faculty Committee
Royal College of Pathologists of Australasia
207 Albion Street
Surry Hills NSW 2010
Enquiries
Gemma Robson
gemmar@rcpa.edu.au
02 8356 5824
Nomination by RCPA College Fellow (FRCPA)
I, _____________________________________ a Fellow of the Royal College of Pathologists of Australasia
(FRCPA), nominate ________________________________________________________________________
for Founding Fellowship of the Faculty of Clinical Forensic Medicine
Signature _________________________________
Contact___________________________________
PRIVACY AND CONFIDENTIALITY
Any personal information you provide is strictly confidential to the College. However, in the course
of considering your application, it may be necessary for the College to provide your contact details and information
about your application to College committees and Fellows of the College who are involved with assessment of
applicants. If the personal information is not provided to the College, the College may be unable to process your
application, or to review and assess your application. The College will manage your personal information in
accordance with its Privacy Policy. If you would like to access information we hold about you or obtain a copy of the
Privacy Policy please contact our Privacy Officer on + 61 2 8356 5858.
I agree to the use of my personal information as outlined above. The information provided in this application is
current, true and correct.
________________________________________
Signature
___________________________
Date
APPLICATION FOR ADMISSION AS A FOUNDING FELLOW, FACULTY OF CLINICAL FORENSIC MEDICINE
I hereby apply for admission as a Founding Fellow, Faculty of Clinical Forensic Medicine of The Royal College of
Pathologists of Australasia, under the provisions of Rule 17 of the College Constitution and the By-laws of the
Faculty. If admitted, I agree to be bound by the Code of Ethics of the College and to comply with the Constitution
and By-laws of the College, as they may be applicable to Fellows of the Faculty of Clinical Forensic Medicine RCPA.
Details (Please use block letters)
Title:________ Surname:___________________________Given Names:_________________________________
Address (for correspondence): __________________________________________________________________
___________________________________________________________________________________________
State:__________________ Post Code: ____________ Country:_______________________________________
Telephone (w): _________________ (h): __________________E-mail: _________________________________
Date of Birth: _________________ Place of Birth______________________ Nationality: ____________________
Gender:
1.
Male
Female
Medical Registration
I am a registered medical practitioner entitled to work in ___________________________, my country of domicile.
Medical Registration Number__________________________ Country of Registration_____________________
Signature:_________________________________________
Date ________________________________
2.
QUALIFICATIONS
Certified copies of original certificates must be presented. Please do not send originals as the College cannot be
held responsible for the custody or return of documents. Certification must be by a Justice of the Peace or a
registered legal practitioner. Overseas applicants must have their copies certified by a Justice of the Peace or
Commissioner for Oaths.
Qualification
Primary Medical Degree
Additional Qualifications
Awarded by
Year
3.
CLINICAL PRACTICE
Forensic Pathologists will need to demonstrate aspects of clinical practice that relate to the living
Date (most recent first)
From - To
Practice/Organisation Name
Full Time Equivalent
Clinical Medicine
Full Time Equivalent
Clinical Forensic
Medicine
Totals (For office use
only)
If your Full Time equivalent (FTE) does not meet the criteria please give further detail including on call
responsibilities and caseload experience.
4.
OTHER REQUIREMENTS
Candidates for Founding Fellowship will also need to demonstrate one or more of the following:
4.1 ACHIEVEMENT
Candidates must be able to demonstrate a national and/or international Profile in Clinical Forensic
Medicine, or a significant leadership role for a Clinical Forensic Medical Service within a nationally
recognised institution as evidenced by;
Senior roles in the field of clinical forensic medicine (name of Organisation, position held, years)
Presentation of research findings at conferences and or invitations to be a speaker at
national/international meetings (details of meeting, presentation, year)
Being involved in Clinical Forensic Medical Scientific bodies or journals (eg editor, reviewer)
Other activities showing achievement in Clinical Forensic Medicine
Year
4.2 ACADEMIC
Active participation in the teaching of Clinical Forensic Medicine
A University appointment for the purpose of teaching Clinical Forensic Medicine to
undergraduates/postgraduates, teaching of other medical practitioners, specialist/postgraduate
trainees
Supervision of a higher degree research student
Delivering courses in CFM on behalf of a University or appropriate medical or scientific body
4.3 RESEARCH AND PUBLICATIONS;
You may attach your list of research and publications as a separate list if you wish
Publications (sole or joint author) based on research carried out or supervised by the applicant in
the field of CFM, in peer-reviewed journals,
Chapters, textbooks or other publications on Clinical Forensic Medicine - topics authored, coauthored or edited by the applicant (please specify).
5. ADDITIONAL INFORMATION (only needs to be addressed if above criteria 1 – 4 are not met)
In exceptional circumstances, Founding Fellowship may be awarded to medical practitioners who have a relevant
appointment in this specialty and do not fulfil all of the above criteria, but who are working in and have made
significant contributions to the field of Clinical Forensic Medicine.
5.1 Two references from suitably qualified or prominent sources in the CFM or legal professions should be
tendered in support of these applicants; please attach if relevant.
Additional information:
PAYMENT
The non-refundable application Fee for Founding Fellow of the Faculty of Clinical Forensic Medicine is $200
Please make Cheques payable to RCPA or pay by credit card
Credit card type:
Visa
MasterCard
Amex
Card Number:
Expiry Date:
/
Print name on the card: ____________________________
CCV/Security Code: __________
Signature: _____________________________