(SAMPLE ONLY) Application for Membership or Fellowship

***NOTE: THIS IS FOR YOUR INFORMATION ONLY! TO APPLY, YOU MUST ASK FOR A CURRENT APPLICATION PACKAGE FROM THE REGISTRAR.

Section 1. General Information

Name:
 FIRST   MIDDLE OR INITIAL   LAST
(Enter name as you want it to appear on your certificate)

Title: Mr. Ms. Dr. Mrs. Date of Birth
DAY/MONTH/YEAR
Address:
Phone:
Fax:
E-mail:
Postal Code:
References:
Medical Physicist:
  Name:
Certification:
Institution:
Phone:
Address:
Relation to Applicant:
Medical Physicist:
  Name:
Certification:
Institution:
Phone:
Address:
Relation to Applicant:
References (continued)
Physician:
  Name:
Certification:
Institution:
Phone:
Address:
Relation to Applicant:

Section 2. Provide the information requested below on this sheet or a separate sheet or, for Sections 2.1 to 2.3, indicate that the information is clearly stated in your attached CV:

2.1 Education:

( or see CV)
INSTITUTION MAJOR DATES ATTENDED DEGREE


2.2 Professional Societies (including other certifications):

(or see CV)
SOCIETY DATES MEMBERSHIP GRADE OFFICES HELD

2.3 University, Cancer Clinic and Hospital Appointments:

( or see CV)
INSTITUTION DEPARTMENT APPOINTMENT DATES

2.4 Professional experience:

EMPLOYER TITLE OR POSITION DUTIES DATES

Section 3. Application for Membership and/or Fellowship

Fill out A and/or B plus part C.

A. Membership:

I am applying to take the 199   membership exam and submit that as of    /   /    (date) I will have       years of patient-related experience as defined in the application instructions.

B. Fellowship

I am applying to take the 199   fellowship exam. As of    /   /     (date) I will have the following credits toward the required seven years experience in medical physics:

Claim one year equivalent credit for an M.Sc. in a field related to medical physics or one year for a Ph.D in an unrelated field or three years for a Ph.D. in a related field:
Claim Years:         
(Claim a maximum of one of the above.)
Optionally claim one-quarter year equivalent credit for each full paper on medical physics (excluding abstracts) in peer reviewed journals.
(Indicate the papers in your CV.)
Claim Years:         
Claim one year for each year of full time equivalent on-the-job experience in medical physics (including the patient-related experience required for membership but not any time spent as part of a successful degree program):
(A minimum of four years is required.)
Years:         

  Total Years:         

 

C. I am applying for certification in the following sub-specialty:

Radiation Oncology Physics
Nuclear Medicine Physics
Diagnostic Radiological Physics
Magnetic Resonance Imaging
I certify that the information contained in this application and in the accompanying curriculum vitae is true. I agree to accept the Board of The Greek College of Physicists in Medicine as the sole judge of my qualifications in order to be and to remain a Member or Fellow of the College. I authorize the CCPM to contact individuals and/or institutions for any confirmation that is needed.

 

Signed