Graduate Certificate in Medical Devices Regulatory Affairs (MDRA)

Application Form

NOTE: Please hover the grey areas to fill up the content.

Section 1: APPLICANT’S PARTICULARS
Title (Mr/Mrs/Ms/Mdm/Dr) / /
Surname / Family Name
Full Name (as in NRIC/Passport)
NRIC / Passport number
Gender / Male / Female
Date of Birth (DD/MMM/YYYY) / Photograph of Applicant
Place of Birth / Country of Residence
Home Address / Mailing Address
(only if different from Home Address)
Email Address
Telephone (H) / (O) / (HP)
Fax no.
Citizenship / Singaporean / Others: Please specify
Singaporean PR
For Singaporeans & Malaysians only / Singaporean Pink IC / Malaysian Pink IC
Singaporean Blue IC / Malaysian Blue IC
National Service (NS) Singaporeans only / Completed - ORD:
Currently Serving - ORD:
Disrupted / Exempted / Not Applicable
Marital Status / Single / Married / Widowed / Divorced
Separated / No of children (if applicable) /
Section 2: PARTICULARS OF NEXT-OF-KIN
Title / Full Name
Home Address
Relationship / Telephone number
Section 3: ACADEMIC QUALIFICATION
(Please attach original/certified true copies of certificates)
From (YYYY) / To (YYYY) / Institution Attended / Degree / Class Rank
Section 4: WORK EXPERIENCE
(Please include your current occupation)
From (MM/YYYY) / To (MM/YYYY) / Organisation & Department / Title and Job Description
Section 5: SCHOLARSHIPS, PRIZES OR OTHER AWARDS RECEIVED
From (YYYY) / To (YYYY) / Details / Organisation
Section 6: MEMBERSHIP OF PROFESSIONAL ORGANISATIONS
From (YYYY) / To (YYYY) / Organisation / Membership status
Section 7: MAJOR EXTRA-CURRICULAR ACTIVITIES/ COMMUNITY ACTIVITIES
From (YYYY) / To (YYYY) / Activites / Office Position Held / Honours / Elected / Appointed
Section 8: LANGUAGES
Spoken / Written
Language(s) / Fair / Good / Excellent / Fair / Good / Excellent
Section 9: OTHER INFORMATION
Have you previously applied for admission or been admitted to any postgraduate program(s) at NUS? / Yes / No
If Yes, please give details below:
Programme Applied For / Year Applied / Outcome
Successful / Rejected
Section 10: SUPERVISOR
(Please indicate your supervisor’s particulars. Supervisor refers to your Reporting Officer at your current workplace.)
Name / Designation
Address
Telephone no. / Fax no.
Email
Section 11: SOURCE OF FINANCE
Self-funded.
Company Sponsorship (Please enclose the Letter of Recommendation from your Supervisor)
Others (please specify): /
Section 12: PERSONAL STATEMENT
(Please discuss your academic and career objectives. You may want to use an additional sheet if necessary)
Section 13: DECLARATION
1 / Have you ever been convicted of any offence by a court of law in any country or are there any court proceedings against you anywhere in respect of any offence? / Yes / No
2 / 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
3 / Are you currently, or have your ever been, under investigation or subject to enquiry in respect of any misconduct, scholastic or otherwise, at any educational institution? / Yes / No
If you have answered “Yes” to any of the above questions, please provide a full statement of relevant information on a separate sheet on paper, and attached the relevant documents.
  1. I hereby declare that all information provided by me on this application form is true, accurate and complete.
  2. 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.
  3. I hereby authorize NUS to obtain and verify any part of the information given by me from or with any source, as it deems appropriate.

PAYMENT OF APPLICATION FEES
Application Fee inclusive of GST (non-refundable) / SGD 42.80
PAYMENT MODE
Cheque / Bank Draft No*
*Cheque / bank draft should be made payable to “National University of Singapore”
SUBMISSION OF APPLICATION FORM
Mailing Address: / Attn: MDRA Programme Administrator (Mr. YEO Kun Song)
Department of Biomedical Engineering
Faculty of Engineering, National University of Singapore
Block E4, #04-8, 4 Engineering Drive 3
Singapore 117583
Phone: / +65 6516 3149
Email: /

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