RCOG Registration No. *

Name of Member  *

Date of Membership  *

Home Address  *

Date of Birth  *

Telephone  *

Fax  *

Name and address of principal place of work  *

Current appointment with date of commencement  *

Describe any significant contribution by you to Obstetrics and Gynaecology  *

How do you think this fellowship will benefit your future career  *

I am a medical practitioner currently registered with  *

I confirm that I am NOT currently:
• Suspended or removed from medical practice by any authorising body,
• Involved in professional disciplinary proceedings, or
• Under any investigation related to my medical practice in any country
• Involved in any civil or criminal investigations

The following active Fellows / Members have agreed to support my application  *

Date of Registration  *