sgh alumnus form

1
Application Form
2
Summary
3
Acknowledgement

Part A: Personal Particulars

A1. Salutation : *

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 : *

Postal Code : *

A8. Email : *

A9. Contact Number :

Mobile :

Office :

Home :

Fax (Optional) :

A10. Nationality : *

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 : *

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) :

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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