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Page Content
1
Application Form
2
Summary
3
Acknowledgement
Part A: Personal Particulars
A1. Salutation :
*
Please select...
Assoc Prof
Dr
Mr
Mrs
Ms
Prof
A2. First Name :
*
A3. Last Name :
*
A4. MCR Number :
A5. Date of Birth
*
(DD/MM/YYYY)
:
A6. Gender :
*
Male
Female
A7. Address :
Address Line 1 :
*
Address Line 2 :
Town/City :
*
Area/Country :
*
Please select ...
Afghanistan
Albania
Algeria
Andorra
Angola
Anguilla
Antigua & Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia & Herzegovina
Botswana
Brazil
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
French Guiana
Gabon
Gambia
Georgia
Germany
Ghana
Great Britain
Greece
Grenada
Guadeloupe
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel and the Occupied Territories
Italy
Ivory Coast (Cote d'Ivoire)
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic Republic of (North Korea)
Korea, Republic of (South Korea)
Kosovo
Kuwait
Kyrgyz Republic (Kyrgyzstan)
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar/Burma
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Ireland
Norway
Oman
Pacific Islands
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Republic of Macedonia
Reunion
Romania
Russian Federation
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent's & Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovak Republic (Slovakia)
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor Leste
Togo
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Turks & Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America (USA)
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands (UK)
Virgin Islands (US)
Yemen
Zambia
Zimbabwe
Postal Code :
*
A8. Email :
*
A9. Contact Number :
Mobile :
Office :
Home :
Fax
(Optional)
:
A10. Nationality :
*
Please select ...
Afghanistan
Albania
Algeria
Andorra
Angola
Anguilla
Antigua & Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia & Herzegovina
Botswana
Brazil
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
French Guiana
Gabon
Gambia
Georgia
Germany
Ghana
Great Britain
Greece
Grenada
Guadeloupe
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel and the Occupied Territories
Italy
Ivory Coast (Cote d'Ivoire)
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic Republic of (North Korea)
Korea, Republic of (South Korea)
Kosovo
Kuwait
Kyrgyz Republic (Kyrgyzstan)
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar/Burma
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Ireland
Norway
Oman
Pacific Islands
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Republic of Macedonia
Reunion
Romania
Russian Federation
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent's & Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovak Republic (Slovakia)
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor Leste
Togo
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Turks & Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America (USA)
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands (UK)
Virgin Islands (US)
Yemen
Zambia
Zimbabwe
A11. Interests
(Optional)
:
A12. Areas for Alumnus Activities :
(Please indicate your most favourite activity as 1, and least as 6.)
Continuing Medical Education :
Access to education resources :
SGH Lecture & Formal Dinner :
Social Gatherings
(eg. SGH Year-end Party, Dinner & Dance, Karaoke)
:
Golf Games/Tournament :
Others
(please state)
:
A13. Remark :
Part B: Professional Particulars
B1. Professional Particulars :
*
GP
Specialist
Retiree
Others
B2. Specialty
(optional)
:
B3. Name of Clinic/Hospital :
*
B4. Address :
Address Line 1 :
*
Address Line 2 :
Town/City :
*
Area/Country :
*
Please select ...
Afghanistan
Albania
Algeria
Andorra
Angola
Anguilla
Antigua & Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia & Herzegovina
Botswana
Brazil
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
French Guiana
Gabon
Gambia
Georgia
Germany
Ghana
Great Britain
Greece
Grenada
Guadeloupe
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel and the Occupied Territories
Italy
Ivory Coast (Cote d'Ivoire)
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic Republic of (North Korea)
Korea, Republic of (South Korea)
Kosovo
Kuwait
Kyrgyz Republic (Kyrgyzstan)
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar/Burma
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Ireland
Norway
Oman
Pacific Islands
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Republic of Macedonia
Reunion
Romania
Russian Federation
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent's & Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovak Republic (Slovakia)
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor Leste
Togo
Tonga
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Turks & Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America (USA)
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands (UK)
Virgin Islands (US)
Yemen
Zambia
Zimbabwe
Postal Code :
*
Part C: Medical Qualification
Basic Qualification
C1. Name of Basic Qualification :
*
C2. University/Institution :
*
C3. Year of Graduation
*
(yyyy)
:
Postgraduate Qualification
D1. Name of Postgraduate Qualification :
(Highest and/or most recent qualification)
D2. University/Institution :
D3. Year of Graduation
(yyyy)
:
D4. Other Qualifications
(optional)
:
Name of other qualifications
*
:
University/Institution
*
:
Year of Graduation
*
(yyyy)
:
Save
Add Other Qualifications
D5. Attachment At SGH
(Max. 2 & Min. 1 record is compulsory)
From
To
Department
Designation
Part D: Declaration
I hereby declare that the particulars stated in this application are true to the best of my knowledge and belief, and I have not willfully suppressed any material fact.
By providing the information set out in this form and submitting the same to you, I confirm that I have read, understood and consent to the SingHealth Data Protection Policy, a copy of which is available at
http://www.sgh.com.sg/Others/contact-us/Pages/PDPA.aspx
.
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