Application for Trainee Membership

Prefix

First Name *

Last Name *

Current year of training (ST3 etc) *

Current Main Hospital/Clinic or Institution *

Qualifications

Post nominals only- please do not include awarding bodies or years awarded

Qualifications

Date of Birth

Date of Birth *

Medical Council Number

GMC/IMC Number *

Approximate date of completion of training

Approximate date of completion of training *

SexFemaleMale

Address

Please provide an address for correspondence regarding your application

Home or WorkHomeWork

Address1

Address2

Town

County

Postcode

Country

Phone1

Mobile *

Contact Email Address of Choice *

Verify Contact Email *

Joining Statement

Please state why you wish to join IAPS, and what you think you will contribute to the Association0 / 500

Membership of other organisations0 / 500

Supporting documents

Please attach a 2 page CV and a document to confirm your NTN

Two referees who must be full members of IAPS

Proof of Trainee Number *

No file chosen

Please upload a copy of your Certificate of Completion of Specialist Training or a letter from the Irish Medical Council confirming your place on the Specialist Register.

CV *

No file chosen

Name - Referees 1 *

Address Referee 1 *

Name - Referees 2 *

Address Referee 2 *

Declaration

All members of IAPS must adhere to IAPS' code of practice, code of conduct and Articles of Association

Click the above links to view these documents before selecting the below boxes to confirm if elected, you will abide by these documents.

By ticking the above boxes, you are confirming that you:

have read and understood and agreed to comply with IAPS codes of Practice and Conduct
that you have complied with IAPS codes, guidelines and standards in your professional practice over the previous 12 months
agree to submit to a IAPS disciplinary procedure if a complaint is made against you and to be bound by the outcome of the procedure

Declaration

Membership is discretionary and subject to the payment of an annual Agree to abide by the rules of membership at all times

Codes of practice and conduct

I give consent

IAPS communications *

a) Whatsappb) emailc) PostalI agree to be added to the IAPS communications via a) Whatsapp b) email c) Postal