APPLICATION FORM - Yong Loo Lin School of Medicine

Yong Loo Lin School of Medicine
Division of Graduate Medical Studies
APPLICATION FORM
Final MMed (Diagnostic Radiology)/ Final FRCR (Part B) Examination
Preparatory Course
[2 - 3 MARCH 2013]
Name: (as in NRIC/Passport)
(pls underline surname or family name)
Mailing Address:
(Please write in CAPITAL
LETTERS)
NRIC/Passport No.: Gender: Male / Female*
Date of Birth (dd/mm/yy): Citizenship:
Marital Status: Single/ Married/ Divorced/ Widowed* Nationality:
Home Tel No.:
Handphone No.:
Email Address:
Tertiary Education:
Postgraduate Medical
Qualifications
Registration as Qualified
Medical Practitioner:
Current Employment:
Current Exam Status (Please Tick)
( ) Post-FRCR 1 only
( ) Post-FRCR 2A (2 or fewer modules)
( ) Post-FRCR 2A (3 - 5 modules)
( ) Post-FRCR 2A (6 modules)
I have previously attended this course
(if yes, state when)
* Please delete where not applicable.
Name of University Period Certificate
Institution of Award Name of
Exam
Institution of Award Name of
Exam
Date Passed
(dd/mm/yy)
Date Passed
(dd/mm/yy)
Year of Registration Country
(designation/ dept/
hosp)
Please provide
two (2)
recent
passport-sized
photos.
Thank you.

PAYMENT DETAILS
Mode of payment: Cheque Bank draft Credit/Debit card
(Tick as appropriate)
For Cheque/Bank draft payment:
No. Description Cheque/Bank draft No. Amount (SGD)
1. Application fee:
2. Course fee:
Note: Cheques/Bank drafts should be made payable to the “National University of Singapore” and indicate your name on
the back of the cheques/bank drafts. Please provide separate cheques/ bank drafts for application and course fees.
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Authorized amount to be withdrawn (SGD):
Card Number:
Expiry date:
Signature of cardholder:
DECLARATION
* Please delete where not applicable.
/
Application fee
Course fee
Last three-digit security number:
MM YY (found on the reverse of your card)
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 examination.
- - -
Signature of Applicant Date
Please send completed application form together with payment, before closing date, to
Ms Kimberly Yang/ Ms Gileen Lacanilao
Division of Graduate Medical Studies, Yong Loo Lin School of Medicine
National University of Singapore, 12 Medical Drive, Block MD5 Level 3,
Singapore 117598, Tel: (65) 6601 1989/ 6516 4915, Fax: (65) 6773 1462
Email: kimberley_yang@nuhs.edu.sg/ gileen_lacanilao@nuhs.edu.sg
Website: www.med.nus.edu.sg/dgms
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)
Application fee
Course fee
Receipt No.:
Date