Paperapplicationform_2011Intake.doc

1、Yong Loo Lin School of MedicineDivision of Graduate Medical StudiesMASTER OF CLINICAL INVESTIGATION APPLICATION FORMCourse of Study: Part Time(A) PERSONAL PARTICULARS (PLEASE WRITE IN BLOCK LETTERS)1. NAME (as in official document) (Dr) SURNAME/FAMILY NAME GIVEN NAME 2. PASSPORT/NRIC/FIN NO. 3. DATE

2、 OF BIRTH (d/mmm/yy)4. TYPE OF NRIC : Tick accordinglySpore Pink Spore Blue Others (Please specify)5. HOME/PERMANENT ADDRESS6. MAILING ADDRESS (If different from home/permanent address. Please do not give P.O.Box address)7. TEL NO (HOME) 8. TEL NO (OFFICE) 9. MOBILE NO 10. EMAIL 11. RACE : Tick acco

3、rdinglyChinese Malay Indian Others (Please specify) 12. GENDER: Female 13. MARITAL STATUS : Single14. DOMICILE (DOM) / PLACE OF BIRTH (POB) Tick accordinglyCOUNTRY DOM POBSingaporeOthers (Please specify )15. CITIZENSHIP (For Non Singaporeans, please indicate if you are also a Singapore PR) Tick acco

4、rdinglySingapore Singapore PR Malaysia BruneiBangladesh India China MyanmarPakistan Philippines Indonesia Sri LankaOthers (Please specify)1 Passport-sized photo(B) ACADEMIC QUALIFICATIONS1. SECONDARY EDUCATIONFrom (Year) To (Year) Name of School / Country Qualification obtained2. ACADEMIC QUALIFICAT

5、IONS (Please attach transcripts of each qualification) Tertiary qualification (s) From Date (d/mmm/yy)Date Passed (d/mmm/yy)Institution(s) / Country Sponsored/ Subsidized by the Singapore Governmnent?NoAdvanced Diploma qualification(s)From Date (d/mmm/yy)Date Passed (d/mmm/yy)Institution(s) / Countr

6、yNoNoPostgraduate Qualification (s) From Date (d/mmm/yy)Date Passed (d/mmm/yy)Institution(s) / CountryNoNoOther Higher Degree (s) From Date (d/mmm/yy)Date Passed (d/mmm/yy)Institution(s) / CountryNoNo3. MEDICAL REGISTRATIONTypes of Medical Registration: Tick accordingly Full Registration Conditional

7、 RegistrationTemporary Registration Provisional RegistrationIf not registered in Singapore: Country: Year of Registration: 4#. TOEFL Score obtained : OR IELTS score obtained: #For international applicants whose native tongue or medium of undergraduate instruction is not English.(C) WORKING EXPERIENC

8、E1. Current position / PostingDesignation: From: To: (d/mmm/yy) (d/mmm/yy)Name of Hospital/ Institution & Dept: Mailing Address: Country: Name of Head of Dept: Brief Job Description: 2. Previous postings/working experience (in chronological order, starting from the most recent), excluding internship

9、/housemanship postings Designation: From: To: (d/mmm/yy) (d/mmm/yy)Name of Hospital/ Institution & Dept: Mailing Address: Country: Name of Head of Dept: Brief Job Description: Designation: From: To: (d/mmm/yy) (d/mmm/yy)Name of Hospital/ Institution & Dept: Mailing Address: Country: Name of Head of

10、Dept: Brief Job Description: Designation: From: To: (d/mmm/yy) (d/mmm/yy)Name of Hospital/ Institution & Dept: Mailing Address: Country: Name of Head of Dept: Brief Job Description: Designation: From: To: (d/mmm/yy) (d/mmm/yy)Name of Hospital/ Institution & Dept: Mailing Address: Country: Name of He

11、ad of Dept: Brief Job Description: Designation: From: To: (d/mmm/yy) (d/mmm/yy)Name of Hospital/ Institution & Dept: Mailing Address: Country: Name of Head of Dept: Brief Job Description: (D) PERSONAL STATEMENTPlease attach a brief statement (approximately 1 page) on a separate sheet, to include the

12、 following: Your past experience and current role in Clinical Research The relevance of this course to your work Your goals after the completion of this course (E) PREVIOUS APPLICATIONS1. Have you previously applied for admission or been admitted to any postgraduate coursework program(s) in NUS?Tick

13、 accordinglyYes No (If yes, please state program applied for: )Year of Application: Outcome of application: SuccessfulDate of Enrolment : From To Current Status: Graduated2. Are you applying for any other postgraduate program at NUS for the coming session? Tick accordinglyYes No (If yes, please stat

14、e program applied for: )(F) SOURCE OF FINANCE1. Intended Source of Finance: Tick accordinglySelf-Support NRF-MOH Scholarship for MCI Others (Please specify )2. Are you an Advanced Trainee? Tick accordinglyYes No(If yes, please indicate your specialty and year of training )3. Have you completed the M

15、aster of Medicine degree or equivalent? Tick accordinglyYes No(G) PARTICULARS OF NEXT-OF-KIN1. Full Name: (Mr) 2. Relationship: 3. Occupation: 4. Email: 5. Tel No.: 6. Mobile No.: 7. Home Address : (H) DECLARATION Tick accordinglyHave you ever been convicted of any offence by a court of law in any c

16、ountry or are there any court proceedings pending against you anywhere in respect of any offence?Yes NoAre you currently, or have you ever been, charged with or subject to disciplinary action for any type of misconduct, scholastic or otherwise, at any educational institution? Yes NoAre you currently

17、, or have you ever been, under investigation or subject to enquiry in respect of any misconduct, scholastic or otherwise, at any educational institution? Yes NoIf your answer to any or all of the above questions is yes, please provide a full statement of relevant information on a separate sheet of p

18、aper (and attach the relevant documents). Declaration by ApplicantI hereby declare that all information provided by me in connection with this application is true, accurate and complete. I understand that any inaccurate, incomplete or false information given or any omission of information required s

19、hall render this application invalid and NUS may at its discretion withdraw any offer of acceptance made to me on the basis of such information or, if already admitted, I may be liable to disciplinary action, which may result in my expulsion from NUS. And I hereby authorise NUS to obtain and verify

20、any part of the information given by me from or with any source, as it deems appropriate._ _Signature of Applicant DatePlease send the completed application form together with a cheque / bank draft of $(S) 40.00 (non-refundable) as application fees made payable to“National University of Singapore” toAttn: Course Administrator, Master of Clinical InvestigationDivision of Graduate Medical StudiesYong Loo Lin School of MedicineNational University of SingaporeMD5, Level 3, 12 Medical DriveSingapore 117598