Portfolio Section 1 : Personal details (FOR YOUR RECORD)
Faculty of Public Health
Confidential
1. PERSONAL DETAILS
Mail title and mailing address
Work address (if applicable and different)
Mail title
Addres
Address
Town
County
Postcode
Country
Town
County
Postcode
Country
Employer
Forename(s)
Post title
Surname
Work telephone number
Title
Mobile telephone number (optional)
Civil & academic honours and degrees
Preferred email address
Date of birth
Secondary email address (optional)
Sex
2. PROFESSIONAL REGISTRATION
Register name (GMC / GDC / UKPHR)
Registration specialty
Registration number
Date of specialist registration
3. CONTINUING PROFESSIONAL DEVELOPMENT
Are you participating in the Faculty of Public Health CPD scheme?
Yes / No
Are you participating in another organisation’s CPD/CME scheme?
Yes / No
If yes, please give the name of the organisation
Has the Faculty formally exempted you from participation in its CPD scheme?
Yes / No
Please keep this form for your own records. If you are included in the Faculty’s
audit you will need to send a copy of this form to the Faculty office.