Affiliate Membership Application

/

Applicant Information

Title (Mr, Mrs, Ms, Miss, Dr, Professor):
First Name:
Surname:
GMC number: / Date of Birth: / Gender:
Mailing address:
City: / Post Code: / Country:
Telephone (W): / Telephone (H): / Mobile:
Email Address:
College Membership / ID number (if known):

appointments held

Current position:
Current employer:
Employer address:
Postcode:
Position:
Hospital grade:
RELEVENT DEGREES AND DIPLOMAS
SPECIAL INTERESTS
Please list up to 3 areas that you have a special interest in e.g. Glaucoma.

1.

2.

3.

SEARCHES

Please indicate below if you agree to the following:
Search in members area:
Allows other members of the College to search for your name, hospital, and special interests. / YES / NO
Include email address:
Allows other members of the College to search as above and includes your email address. / YES / NO
List in public area:
Name is listed under ‘Patient Information – looking for a consultant’ on the College’s website. (UK NHS consultants only) / YES / NO

Affiliate Membership Application

/
SERVICES
Please indicate below services you would like access to.
Access to CPD only:
Access to CPD and E-Portfolio:
For overseas applicants wishing to have access to the e-portfolio, please state the reason why:
DECLARATION
1.  Have you at any time had (or do you have pending) any criminal convictions? / YES / NO
2.  Have you at any time had (or do you have pending) warnings, suspensions, limitations or removal of medical registration in any country? / YES / NO
3.  Are there any reasons why a certificate of good standing might be refused in any country where you have worked? / YES / NO
4.  Do you have any health problem likely to adversely affect your professional work? / YES / NO
5.  Are you aware of any matters that may affect your good standing as a member of The Royal College of Ophthalmologists? / YES / NO
6.  If you have answered ‘Yes’ to any of the above questions please give an explanation below:
7.  I confirm that I have complied with my employers requirements for annual appraisal. (UK applicants only) / YES / NO
I consent to becoming an Affiliate member of The Royal College of Ophthalmologists and agree to be bound by the Ordinances, Bye-Laws and Conduct Regulations of the College and any amendments to them in the future. To further, to the best of my ability, the objectives and best interests of the College and to uphold the best possible standards in relation to ophthalmology and patient care. I agree to comply with the terms of the College’s Code of Conduct when acting in any capacity on behalf of the College. I agree to inform the College promptly if I become subject to any warnings or limitations imposed by any regulatory body regarding my conduct or performance. I understand that if I fail to pay the appropriate rate of annual subscription, I will cease to be a ‘member in good standing’ of the College.
Signature of applicant: / Date:
NB: Please note that Affiliate membership does not confer post nominals.

Affiliate Membership Application

/
SPONSORS
Please provide the names of two sponsors to support your application. Sponsors must be current Fellows or Members of the College and should know the applicant)
We, the undersigned Fellows or Members of the College, support the application and confirm that the information given by the applicant is, to the best of our knowledge, true.
Applicant’s name:
SPONSOR 1
Name (Please print below): / Membership Number:
SIGNATURE:
SPONSOR 2
Name (Please print below): / Membership Number:
SIGNATURE:
Please return the completed form together with the equal opportunities monitoring form to the email address below. A direct debit form for applicants in the UK should also be completed and sent by post to the address below.
The Honorary Secretary
The Royal College of Ophthalmologists
18 Stephenson Way
London
NW1 2HD

OFFICIAL USE ONLY
AAO O.N.E. Network ☐ Date:
RCOphth e-portfolio / CPD ☐ Date:
Eye Logbook ☐ Date:
Web credential ☐ Date:
Letter ☐ Date:

Page 3 of 3