Nomination Form

Which position are you seeking nomination for?
—Please choose an option—Vice PresidentCouncil

Candidate Name

Membership Number

Your Email

Your proposer and seconder are asked to email enquiries@fsem.ac.uk independently to confirm their support of this nomination

Proposed By

Proposer's Membership Number

Seconded By

Seconder's Membership Number

Candidate Details

Member Since

Main Professional Appointment

Please limit your responses to the following questions to 150 words in total (e.g. 75 words each). These responses will not be edited.

Please outline clearly any duties you currently undertake both on behalf of the Faculty and for Sport and Exercise Medicine in general

Please outline your aspirations for the future regarding involvement with the Faculty

Probity Declaration

By submitting this nomination, I declare that I have not, in the UK or outside:

• Been convicted of a criminal offence (including any spent convictions) or have proceedings pending against me.
• Had any cases adversely considered by the GMC, other professional regulatory body, or other licensing body or have any such cases pending against me.
• Had any disciplinary actions taken against me by an employer or contractor or have had any contract terminated or suspended on grounds relating to my fitness to practice

I agree to the above declaration