Paperapplicationform_2011Intake.doc

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MASTER OF CLINICAL INVESTIGATION APPLICATION FORM

Course of Study: Part Time

(A) PERSONAL PARTICULARS (PLEASE WRITE IN BLOCK LETTERS)

1. NAME (as in official document) ()

SURNAME/FAMILY NAME

GIVEN NAME
2. PASSPORT/NRIC/FIN NO.
3. DATE OF BIRTH (d/mmm/yy)

4. TYPE OF NRIC : [Tick accordingly]
S’pore Pink S’pore Blue Others (Please specify)

5. HOME/PERMANENT ADDRESS

6. 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 accordingly]
Chinese Malay Indian Others (Please specify)

12. GENDER:
13. MARITAL STATUS :

14. DOMICILE (DOM) / PLACE OF BIRTH (POB) [Tick accordingly]
COUNTRY
DOM
POB

Singapore

Others (Please specify )

15. CITIZENSHIP (For Non –Singaporeans, please indicate if you are also a Singapore PR) [Tick accordingly]
Singapore

Singapore PR

Malaysia

Brunei

Bangladesh

India

China

Myanmar

Pakistan

Philippines

Indonesia

Sri Lanka

Others

(Please specify)

(B) ACADEMIC QUALIFICATIONS

1. SECONDARY EDUCATION

From (Year)
To (Year)
Name of School / Country
Qualification obtained

2. ACADEMIC QUALIFICATIONS (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?

Advanced Diploma qualification(s)
From Date (d/mmm/yy)
Date Passed (d/mmm/yy)
Institution(s) / Country

Postgraduate Qualification (s)
From Date (d/mmm/yy)
Date Passed (d/mmm/yy)
Institution(s) / Country

Other Higher Degree (s)
From Date (d/mmm/yy)
Date Passed (d/mmm/yy)
Institution(s) / Country

3. MEDICAL REGISTRATION

Types of Medical Registration: [Tick accordingly]
Full Registration
Conditional Registration

Temporary Registration
Provisional Registration

If 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 EXPERIENCE

1. Current position / Posting

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:

2. Previous postings/working experience (in chronological order, starting from the most recent), excluding internship/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 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 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 Dept:
Brief Job Description:

(D) PERSONAL STATEMENT

Please attach a brief statement approximately 1 page) on a separate sheet, to include the 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 APPLICATIONS

1. Have you previously applied for admission or been admitted to any postgraduate coursework program(s) in NUS?
[Tick accordingly]

Yes
No
(If yes, please state program applied for:)
Year of Application:
Outcome of application:
Date of Enrolment : From To
Current Status:

2. Are you applying for any other postgraduate program at NUS for the coming session? [Tick accordingly]

Yes
No
(If yes, please state program applied for:)

(F) SOURCE OF FINANCE

1. Intended Source of Finance: [Tick accordingly]
Self-Support NRF-MOH Scholarship for MCI Others (Please specify )

2. Are you an Advanced Trainee? [Tick accordingly]
Yes No
(If yes, please indicate your specialty and year of training )

3. Have you completed the Master of Medicine degree or equivalent? [Tick accordingly]
Yes No

(G) PARTICULARS OF NEXT-OF-KIN

1. Full Name: ()
2. Relationship:

3. Occupation:
4. Email:

5. Tel No.:
6. Mobile No.:

7. Home Address :

(H) DECLARATION [Tick accordingly]

Have you ever been convicted of any offence by a court of law in any country or are there any court proceedings pending against you anywhere in respect of any offence?
Yes No

Are 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 No

Are you currently, or have you ever been, under investigation or subject to enquiry in respect of any misconduct, scholastic or otherwise, at any educational institution?  
Yes No

If 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 paper (and attach the relevant documents).

Declaration by Applicant

I 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 shall 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 any part of the information given by me from or with any source, as it deems appropriate.

_______________________________ _______________________________
Signature of Applicant Date

Please 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” to

Attn: Course Administrator, Master of Clinical Investigation
Division of Graduate Medical Studies
Yong Loo Lin School of Medicine
National University of Singapore
MD5, Level 3, 12 Medical Drive
Singapore 117598