Application Form - Yong Loo Lin School of Medicine

Yong Loo Lin School of Medicine
Division of Graduate Medical Studies
APPLICATION FORM
Introductory Course to Psychotherapy
14 March 2013 – 31 October 2013
(Break: 23 May 2013 – 27 June 2013)
*If you have already attended Part 1 CBT previously, please indicate the year in which
you attend the Part 1 session: ___________
1. PERSONAL PARTICULARS (Please use CAPITAL LETTERS for this section)
Full Name:
(as per NRIC/Passport)
Home/Permanent
Address:
Mailing address:
(if different from the above)
* Please delete where not applicable.
(Please underline surname or family name)
NRIC/Passport No.: FIN No.:
Date of Birth: Gender: Male/Female*
Please provide
two (2)
recent
passport-sized
photos.
Thank you.
Marital Status: Single/ Married/ Divorced/ Widowed* Race: Chinese/Malay/Indian/Others*
Citizenship: Place of Birth:
Email Address: Nationality:
Home Tel No.: Handphone No.:
MCR No. (if any):
Academic/Professional Qualifications (with dates/institutes):
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Current Employment Details (Designation/Dept/Employer):
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________

Yong Loo Lin School of Medicine
Division of Graduate Medical Studies
PAYMENT DETAILS
Mode of payment: Cheque Bank draft Credit/Debit card
(Tick as appropriate)
Please tick to indicate your interest in the boxes below:
Full Course with early bird discount
(valid till 31/01/13)
* Please delete where not applicable.
Full Course
(Part 1 &2) Part 1 (CBT) only Part 2 (Psychodynamic) only
SGD1516.70 SGD1,685.25 SGD642 SGD1,214.45
NOTE: fees stated above exclude a non-refundable application fee of $40 to be made via a separate cheque/draft or credit card
transaction.
For Cheque/Bank draft payment:
Note: Cheques/Bank drafts should be made payable to the “National University of Singapore”. Please indicate your name on
the back of the cheques/bank drafts.
For Credit/Debit card payment:
Note: DBS/POSB Credit/Debit Card would be preferred.
Cardholder Name:
(Please write in CAPITAL LETTERS)
Authorized amount to be withdrawn (SGD):
Application fee
Full Course fee with early bird discount
(valid till 31/01/13)
Credit/ Debit Card Type:
(Tick as appropriate)
Card Number:
Full Course
Part 1 (CBT) only
Part 2 (Psychodynamic) only
$40
Visa MasterCard
Expiry date: / Last three-digit security number:
MM YY (found on the reverse side of your card)
Signature of cardholder:
DECLARATION
- - -
I affirm that all statements made by me on this form are correct. I understand that any inaccurate or false information
(or omission of material information) will render this application invalid and that, if admitted on the basis of such information,
I can be required to withdraw from the programme.
Signature of Applicant Date

* Please delete where not applicable.
Please send completed application form together with payment, before closing date, to
Ms Aw Yu Chen/ Ms Tye Wenxiu
Division of Graduate Medical Studies, Yong Loo Lin School of Medicine
Block MD 5 Level 3 National University of Singapore, 12 Medical Drive (Singapore 117598)
Fax: (65) 6773 1462 Tel: (65) 6601 2425/ 6516 3301 Fax: (65) 6773 1462
Website: www.med.nus.edu.sg/dgms
Email: yu_chen_aw@nuhs.edu.sg / wenxiu_tye@nuhs.edu.sg
For Official Use Only
Cheques/ Drafts No. & Amount: Receipt No.:
Cheques/ Drafts Received on: Receipt Issued on:
Amount in SGD from Credit card / Debit card: Amount (SGD) Receipt No.: Date
Application fee