Application Form - Yong Loo Lin School of Medicine

Yong Loo Lin School of MedicineDivision of Graduate Medical StudiesAPPLICATION FORMPRIMARY MASTER OF MEDICINE (OPHTHALMOLOGY) EXAMINATION –REFRACTION ASSESSMENTDiet applying for:(Please tick as appropriate)2 Feb 2013 (Sat)2 Mar 2013 (Sat)3 Aug 2013 (Sat)7 Sep 2013 (Sat)Please providetwo (2) recentpassport-sizedphotos.Thank you.1. PERSONAL PARTICULARS (Please fill in this section in CAPITAL LETTERS)Name :(As per NRIC/Passport)(Please underline surname/family name)Home/ PermanentAddress:Mailing address:(if different from above)NRIC/Passport No.:Fin No.:Date of Birth: Gender: Male / Female *Marital Status: Single / Married / Divorced / Widowed * Race:Citizenship:Place of Birth:Email Address:Nationality:Home Tel No.:Handphone No.:Particulars of Next-of-Kin: (Name) (Relationship to applicant) (Contact No.)(Address if different from above)2. ACADEMIC QUALIFICATIONSTertiary Education:PostgraduateMedicalQualifications:Name of University Certificate From(dd/mm/yy)Institution of Award Name of Exam From(dd/mm/yy)To(dd/mm/yy)To(dd/mm/yy)Date Passed(dd/mm/yy)Date Passed(dd/mm/yy)Institution of Award Name of Exam From(dd/mm/yy)To(dd/mm/yy)Date Passed(dd/mm/yy)*Please delete where not applicable.Page 1 of 4

Membership ofProfessionalOrganizations: Organization Post Held/Membership Status From(dd/mm/yy)To(dd/mm/yy)Organization Post Held/Membership Status From(dd/mm/yy)Registration asQualified MedicalPractitioner: Year of Registration Country MCR NumberTo(dd/mm/yy)CurrentEmployment: Designation Department Hospital3. HOSPITAL POSTINGSIn chronological order, starting from Houseman/Internship Year. LOCAL CANDIDATES should include national service postings & start ofTraineeship/Residency postings.i)AppointmentFrom(dd/mm/yy)To(dd/mm/yy)Unit/HospitalNo. ofBedsName of Dept Headii)AppointmentFrom(dd/mm/yy)To(dd/mm/yy)Unit/HospitalNo. ofBedsName of Dept Headiii)AppointmentFrom(dd/mm/yy)To(dd/mm/yy)Unit/HospitalNo. ofBedsName of Dept Headiv)AppointmentFrom(dd/mm/yy)To(dd/mm/yy)Unit/HospitalNo. ofBedsName of Dept Headi)AppointmentFrom(dd/mm/yy)To(dd/mm/yy)Unit/HospitalNo. ofBedsName of Dept Headv)AppointmentFrom(dd/mm/yy)To(dd/mm/yy)Unit/HospitalNo. ofBedsName of Dept Headvi)AppointmentFrom(dd/mm/yy)To(dd/mm/yy)Unit/HospitalNo. ofBedsName of Dept Head*Please delete where not applicable.Page 2 of 4

4. OTHER NON-MEDICAL JOB(S) HELDPlease list, in chronological order, the jobs you have held after obtaining your bachelor’s degree. Attach a separate sheet if necessary.Note: For full-Time NUS staff, please indicate staff no. and attach a copy of appointment letter.i)AppointmentFrom(dd/mm/yy)To(dd/mm/yy)Name ofCompany/DepartmentNature of workii)AppointmentFrom(dd/mm/yy)To(dd/mm/yy)Name ofCompany/DepartmentNature of workiii)AppointmentFrom(dd/mm/yy)To(dd/mm/yy)Name ofCompany/DepartmentNature of work5. ENGLISH LANGUAGEPROFICIENCYSpoken: Excellent/ Good/ Fair/ Poor * Written: Excellent/ Good/ Fair/ Poor *6. PREVIOUS APPLICATIONSi) I am applying to sit this exam for the first timeYes No If no, please state the year of previous attempts:ii) Have you previously applied for admission or been admitted to any postgraduate coursework programme(s) or examination(s) at NUS?Yes No If yes, please state programme applied for:Year of application: Outcome of application: Successful/ Unsuccessful *Date of enrolment: From toCurrent Status: Graduated/Withdrawn/Failed/Current Student*iii) Are you applying for, have applied or enrolled in any other postgraduate coursework programme or examination at NUS?Yes No If yes, please state details of the programme(s):7. NATIONAL SERVICE Completed / Disrupted / Currently Serving / Exempted / Not Applicable *Please specify (expected ORD), if applicable8. SOURCE OF FINANCEEmployer Sponsorship / Self-Support / Others* (Please specify)Note: Please attach documentary evidence of employer sponsorship.*Please delete where not applicable.Page 3 of 4

9. MODE OF PAYMENTMode of payment:(Tick as appropriate)For Cheque/ Bank draft payment:Cheque Bank draft Credit/ Debit cardNo. Description: Cheque/ Bank draft No. Amount (SGD)1 Application fee:2 Examination fee:Note: Cheque/ Bank draft should be made payable to the “National University of Singapore” and indicate your name on the back of thecheque/ bank draft.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 feeExamination feeCredit/ Debit Card Type:(Tick as appropriate) Visa MastercardCard Number: - - -Expiry date:/Last three-digit found on security number:MM YY (found on the reverse side of your card)Signature of Cardholder:10. DECLARATIONI affirm that all statements made by me on this form are correct. I understand that any inaccurate or false information (or omissionof material information) will render this application invalid and that, if admitted on the basis of such information, I can be required towithdraw from the examination.Signature of ApplicantDateCheque / Draft No. & Amount:Cheque / Draft Received on:Please send completed application form together with payment, before closing date, toMs Jaslyn Ng / Ms Sithira DeviDivision of Graduate Medical Studies, Yong Loo Lin School of MedicineNational University of Singapore, Block MD 5, Level 3, 12 Medical Drive, Singapore 117598Tel: (65) 6601 1499 / 6615 3306 Fax: (65) 6773 1462Email: gsmnywj@nus.edu.sg/ sithira_devi@nuhs.edu.sgFor Official Use OnlyReceipt No.:Receipt Issued on:Amount in SGD from Credit card / Debit card: Amount (SGD) Receipt No.: DateApplication feeExamination fee*Please delete where not applicable.Page 4 of 4