SINGAPORE GENERAL HOSPITAL
APPLICATION FOR ADMISSION AS A SPECIAL CLINICAL STUDENT

1.	Application form must be submitted at least 3 months prior to the commencement date of proposed elective posting, together with an original letter of certification from the Dean of the Faculty of Medicine of the University and supporting documents on Hepatitis screening and proof of health insurance (for non-Singaporean applicants).
2.	Ensure that you have read all the information in Form AD_guide. Failure to complete your application form properly will delay processing and affect your chances of getting a preferred posting.
3.	For clarifications, please email adminado@sgh.com.sg.

All Fields are required except those marked with *.

1. APPLICANT'S PARTICULARS

Title: Mr Mrs Miss	Passport No.:
Name:	Age:
Name:	Citizenship:
Postal Address/E-mail Address:	Tel:
Postal Address/E-mail Address:	Fax: (if available) *
Address in Singapore (if applicable): *	Tel No.in Singapore: *
Address in Singapore (if applicable): *	Fax: (if available) *
Next of Kin:	Address/Tel/Fax No. of Next of Kin:
Relationship:	Address/Tel/Fax No. of Next of Kin:

2. BACKGROUND OF MEDICAL EDUCATION

Name of Parent Medical School:

Address:

Current year of study:

Year of study at time elective with us:

Expected date of qualifying in Medicine:

Indicate briefly clinical experience up to time of proposed elective:

3. PROPOSED ELECTIVE POSTINGS

Overall period of attendance as a special clinical student (please indicate day, month and year)

From: To: (Weeks: )

Choice of Posting (* in order of preference )*	From	To	Duration (Weeks)

*	*	*	*
*	*	*	*

This Elective is part of my academic credit and must be completed within stated period.

Yes NA

Have you been in contact with any staff member at this hospital? (If so, please state name & department. ) *

Application form must be submitted at least 3 months prior to the commencement date of proposed elective posting, and together with an original letter of certification from the Dean of the Faculty of Medicine of the University.

Our mailing address is:�

Singapore General Hospital
Associate Dean
Associate Dean's Office
Block 1, Rooftop level
Outram Road�
Singapore 169608

Fax : (65) 6226-1492
Email :adminado@sgh.com.sg