pgmifellowshipapplication

This form may take one hour to complete.

Part A: SGH Attachment Information

A1. Training Institution *

A2. Choice of Training Department *

A3. Choice of Subspecialty *

A4. Type of Fellowship/ Clinical Attachment *

A5. Source of Funding / Sponsorship *

Note:
All trainees are required to secure own funding to support their attachments and stay in Singapore. Please specify your funding source for this attachment.

Self-Funded
Funded by my current employer
Other source(s), please specify:

A6. Duration *

A7. Application Date

A8. Preferred Start Date

Note:
Due to the time required for administrative procedures, trainees applying for hands on patient management attachment are required to submit application at least 9 months prior to the preferred training start date. Please note that actual training commencement date is subject to completion of the necessary administrative procedures, registration and/or visit pass approvals.

A9. Training Objectives *

Note:
Please specify your training objectives, highlighting information such as the subspecialty & skills/ techniques/ procedures that you wish to learn in this attachment and the result you hope to achieve from this attachment.

(a)Subspecialty:

(b)Skills/Techniques/Procedures:

(c)Reasons for application:

Part B: Personal Particulars

B1. Full Name *

Note:
Please state name as shown on Passport / Identity Card.

B2. Surname/Family Name *

B3. Gender *

Male
Female

B4. Date of Birth *

B5. Age

B6. Nationality *

B7. Marital Status *

Single
Married
Others, please specify:

B8. Country of Residence *

B9. Upload Photo

Note:
One recent digital passport-sized colour photograph that meets the following specifications: Image file in JPEG format ('jpg' extension) with a file size of not more than 60 kb

Part C: Contact Information

C1. E-mail Address *

Note:
Please note that most correspondence will be conducted through this email address, except mailing of hardcopy documents.

C2. Home Address *

C3. Corresponding Address (if different from Home Address)

C4. Contact No. *

Part D: Education/Medical Qualification

Section 1: Basic Medical Degree Listing (Max. 2 & Min. 1 record is compulsory)

D1. Qualification Attained *

D2. Name of Medical College/ School *

D3. Name of Conferring Institution *

D4. Country *

D5. Period of Study: From Date: *

To Date: *

D6. Duration of Study

D7. Date of Conferment *

D8. Upload a PDF copy of your basic medical degree *

Note:
Please upload a PDF copy of your basic medical degree.

Section 2: Postgraduate Medical Degree / Other Degrees / Fellowship (Master of Medicine equivalent) (Max. 3 & Min. 1 record is compulsory)

D1. Qualification Attained *

D2. Name of Medical College/ School *

D3. Name of Conferring Institution *

D4. Country *

D5. Period of Study: From Date: *

To Date: *

D6. Duration of Study *

D7. Date of Conferment *

D8. Upload a PDF copy of your postgraduate Medical *

Note:
Please upload a PDF copy of your postgraduate medical degree/ qualification.

Section 3: Medical Licensure Listing (Max. 2 and min. 1 record is compulsory)

D1. Name of Licensing Authority *

D2. National Medical Licensure No. *

D3. Country *

D4. Membership Type *

D5. Membership Period: From Date *

To Date: *

D6. Duration of Study

D7. Upload a PDF copy of your Medical Licensure *

Note:
Please upload a PDF copy of your current practicing certificate/ license.

Part E: Clinical Appointment/ Experience

Section 1: Rotating internship/ Houseman-ship (Max. 6 & Min. 1 record is compulsory.)

E1. Posting Period: From Date *

To Date *

E2. Posting Specialties / Departments *

E3. Posting Hospital / Institution *

E4. Posting Country *

Section 2: All post-housemanship postings (Max. 6 & Min. 1 record is compulsory.)

E1. Posting Period: From Date *

To Date *

E2. Posting Specialties / Departments *

E3. Hospital / Institution *

E4. Country *

Section 3: Current Position

E1. Current Position Period From Date *

To Date *

E2. Are you still currently employed in this organisation? *

Yes
No

E3. Current Position Duration *

E4. Current Position Specialty / Department *

E5. Current Position Job title *

E6. Current Position Description *

Note:
Please provide a summary of your role and responsibilities in the current position, highlighting the subspecialties, if any. Wherever possible, describe types of cases / patients, working hours, teaching sessions, etc.

E7. Current Position Hospital / Institution Name *

E8. Current Position Hospital / Institution Type *

Public/Government
Private/Others

E9. Current Position Hospital / Institution Address *

E10. Current Position Hospital / Institution website address *

Note:
Hospital's URL.

E11. Current Position Country *

This form may take one hour to complete.

Section 1: Basic Medical Degree Listing (Max. 2 & Min. 1 record is compulsory)

Section 2: Postgraduate Medical Degree / Other Degrees / Fellowship (Master of Medicine equivalent) (Max. 3 & Min. 1 record is compulsory)

Section 3: Medical Licensure Listing (Max. 2 and min. 1 record is compulsory)

Section 1: Rotating internship/ Houseman-ship (Max. 6 & Min. 1 record is compulsory.)

Section 2: All post-housemanship postings (Max. 6 & Min. 1 record is compulsory.)

Section 3: Current Position

English Proficiency

References (Details of Professional Referees)