APPLICATION FORM – 14th & 15th October 2017 (Saturday & Sunday)

(Application Closing Date: 11th September 2017)

Category / Course Fee (S$)

Overseas Doctors

/ $2,250

(Bursary $250 for the first 10 candidates)

Title (Prof/Dr/Mr/Mrs/Miss/Ms): ______

Full Name (as in NRIC/Passport): ______

(Please underline family name)

MCR Registration No:

Email Address:

Please note: all correspondence with course attendees will be sent by email

Home Address (Please note that the course textbook will be mailed to this address):

Telephone: ______Date of Birth:

Employer:

Present Appointment:

Hospital and Specialty:

Grade (CT2/ST2, ST3):

Year started postgraduate training:______

Special Dietary (eg. Vegetarian):

Please tell us how you heard about this course: ______

Fees:

The cost of the course includes a course manual, lunch and refreshments. Please note that the fee does NOT cover accommodation and CGH is unfortunately unable to make arrangements for accommodation on your behalf.

Method of payment (Please tick):

Cheque made Payable to “Changi General Hospital Pte Ltd”

______(Cheque No. & Bank Name)

Please write your name and Programme code: 11801800 at the back of the cheque.

TT/Bank Transfer Account : Changi General Hospital Pte Ltd

Bank Name : DBS Bank Ltd

Bank’s Address : 12 Marina Boulevard,

DBS Asia Central,

Marina Bay Financial Centre Tower 3,

Singapore 018982

Account Number : 003-927294-4

Swift Code : DBSSSGSG

Bank Code : 7171

Branch code : 003

Currency : SGD

Cancellation Policy
A written notice of withdrawal is required to be eligible for any refund on the stipulated timelines as indicated:
·  Cancellations of more than 8 weeks prior to course : 90% refund of course fee
·  Cancellations of less than 8 weeks prior to course : 50% refund of course fee
·  Cancellations of less than 6 weeks prior to course : No refund of course fee
While we make every effort to run courses as advertised, CGH reserves the right to change the timetable and/or the teaching staff without prior notice and to cancel any courses without liability (in which case there will be a full refund of course fees to delegates).
Please be aware that this cancellation policy will be strictly adhered to and by signing the form below you are agreeing to the above statement.
Signed / Date

Please return this completed form (and enclosed cheque for cheque payment) to:

Ms Chong Lu-Lu

Medical Education

Changi General Hospital

2 Simei Street 3

Singapore 529889

Tel: +65 6850-1505

Email: