borang @ form (elective posting) pelajar luar - UKM Medical Centre ...

UNIVERSITI KEBANGSAAN MALAYSIAJALAN YAACOB LATIF, BANDAR TUN RAZAK56000 CHERAS, KUALA LUMPUR, MALAYSIATEL : 603-9145 5555 Ext : 5032 / 5029 FAX : 603-9145 6655PhotoAPPLICATION FOR ELECTIVE POSTINGA. PARTICULARS OF APPLICANTName : Mr/Mrs/Miss ………………………………………………………………………………………………………(In Block Capital as Written in the Passport)Other Name : ………………………………………………………………………………………………………………(If any, including maiden name)Age : ……………………… Sex : ………………………. Citizenship : ……………………………………………...Type of Passport : ……………………………………….. Passport No : …………………………………………….Postal Address : …………………………………………………………………………………………………………..………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Tel. No : ……………………. Fax No : ………………….. E-mail : ……………………………………………………Next of Kin : ………………………………………………………………………………………………………………Address of Next of Kin : …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Tel : ……………………………… Fax : ……………………………Expected date of arrival : ……………………………………………B. BACKGROUND OF MEDICAL EDUCATIONName and address of parent medical school : ………………………………………………………………………...………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Year of study : …………………………Expected date of graduation : …………………………………Indicate briefly your clinical experience to date :………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………(If space is insufficient, please write on a different sheet)

C. PARTICULARS OF ELECTIVE POSTING REQUESTEDOverall period of attendance as elective posting:From : ………………………. To : ……………………….. ( weeks)(Total length of the posting must not exceed 8 weeks. Minimum time spend in particular department should be at least 3weeks and not more than 2 departments)Preferred Postings :Posting (e.g. Medicine, Surgery, O&G, A&E etc)……………………………… (……………………………….(weeks) from : …………………….. to : …………………………….Weeks) from : ………………………to : ……………………………...Have you been in contact with any staff member at this University?(If so, please state name)………………………………………………………………………………………………………………………………Date : ………………………..Signature of applicant : ………………………………..(Copies of document with your Certifying Letter, Transcript of Examination & Course of Study and Curriculum Vitae to beattached with application form)D. SUPPORTING STATEMENT FROM THE DEAN OF PARENT MEDICAL SCHOOLI confirm the standing of the applicant in our medical school and that the proposed elective attachment isconsidered suitable.Additional remarks :……………………………………………………………………………………………………………..………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Date : ……………………………….…………………………………………Signature of Dean……………………………………….Official StampThis form should be returned to:PRINCIPAL ASSISTANT REGISTRAR,UNDERGRADUATE STUDIES,UNIVERSITI KEBANGSAAN MALAYSIA,JALAN YAACOB LATIF, BANDAR TUN RAZAK,56000 CHERAS, KUALA LUMPUR,MALAYSIA.

FAKULTI PERUBATANFACULTY OF MEDICINEUNIVERSITI KEBANGSAAN MALAYSIAPERATURAN & CARA MEMOHONPOSTING ELEKTIF DI FAKULTI PERUBATANUNIVERSITI KEBANGSAAN MALAYSIA(RULES & REGULATIONS FOR ELECTIVE POSTING)1. PEMOHON ADALAH PELAJAR PERUBATAN TAHUN KLINIKAL DAN TELAH MENGIKUTIKURSUS JABATAN YANG DI POHON.(The application should be in a clinical medical year and should have completed the course inthe discipline applying for)2. PERMOHONAN DITERIMA SEKIRANYA LENGKAP DENGAN SURAT PENGESAHANTEMPAT BELAJAR, KEPUTUSAN PEPERIKSAAN & JADUAL KURSUS SERTA BIODATAHENDAKLAH DIHANTAR 3 BULAN SEBELUM TARIKH POSTING YANG DI POHON.(We should receive the completed application form, with your Certifying Letter, Transcriptof Examination & Courses of Study and Curriculum Vitae, 3 months before thecommencing date of elective posting)3. JUMLAH MASA POSTING HENDAKLAH TIDAK MELEBIHI LAPAN (8) MINGGU SERTATIDAK LEBIH DUA (2) JABATAN. MINIMA TIGA (3) MINGGU DI SETIAP JABATAN.(The total length of the posting must not exceed 8 weeks for one or two departments. Theminimum time spend in a particular department should be at least 3 weeks)4. PERMOHONAN POSTING TIDAK DITERIMA SEKIRANYA MELEBIHI DUA JABATAN(Applicants should request for posting in not more than 2 departments)5. PERMOHONAN POSTING TIDAK DITERIMA PADA TARIKH PEPERIKSAAN IKHTISASDALAM BULAN MARCH DAN OKTOBER(The posting must not coincide with the dates of Professional Examinations, which are usuallyheld in the months of March and October)6. BAYARAN PENDAFTARAN KURSUS DIKENAKAN SECARA TUNAI SETELAHPERMOHONAN DILULUSKAN DAN HENDAKLAH DIBAYAR SEMASA MENDAFTAR PADAHARI PERTAMA. SILA RUJUK JADUAL PEMBAYARAN SEPERTI DI BAWAH :(A processing fee cash Ringgit Malaysia is chargeable on acceptance and to be paid on the1 st day of reporting). Please refer to the table :

Perkara/StatePosting elektif tidak melebihi 8 minggu(elective posting less then 8 weeks)Posting elektif tidak melebihi 16 minggu(elective posting less then 16 weeks)Posting elektif tidak melebihi 24 minggu(elective posting less then 24 weeks)Warganegara Malaysia/Malaysian CitizenRM750RM1500RM2250Bukan Warganegara/ForeignerRM1500RM3000RM45007. SILA PENUHKAN BORANG PERMOHONAN ELEKTIF DENGAN TELITI DAN LENGKAPBERSERTA TANDATANGAN DEKAN ATAU PEGAWAI TEMPAT BELAJAR BESERTACOP MOHOR ATAU COP TANDANAMA JAWATAN PEGAWAI DI TEMPAT BELAJAR DANKEMBALIKAN SECEPAT MUNGKIN KEPADA :(Please complete the application form carefully, which must be countersigned by your Deanand accompanied by the official stamp of your faculty and return it to us as soon as possible)Ketua Penolong Pendaftar (Akademik)/Principal Assistant Registrar (Academic)Fakulti Perubatan/Faculty of Medicine, UKMJalan Yaacob LariffBandar Tun Razak56000 Cheras, Kuala Lumpur,MALAYSIATel : 603-9145 5032 / 5029 Fax : 603-9145 6655Web siteEmail: www.ppukm.ukm.my: marzuki@ppukm.ukm.edu.my8. Sekiranya memerlukan penginapan, sila tulis surat permohonan kepada :In need of accommodation, please write to :Pengetua/PrincipalKolej Tun Dr. Ismail/Tun Dr. Ismail College, UKMJalan Yaacob LatiffBandar Tun Razak56000 Cheras, Kuala LumpurMALAYSIATel : 603-9145 6270 Fax : 603-9173 5231