Title*

DrMrMrsMissMsProf

First Name*

Surname*

Calling Name for Name Badge*

Business Address

Postal Address*

Residential Address

Tel (Home)

Fax (Home)

Tel (Business)*

Fax (Business)

Cell Phone*

Email*

Medical Registration No

Nursing Registration No

ID or Passport No

Nationality*

Special diet request

Qualifications*

University Degree and Date*

Highest Surgical Examination*

Date Passed*

Date ATLS® Successfully Completed*

Summary of Experience Over Last Three Years

Internship performed at*

Current appointment*

Reasons for DPNTC® Application*

* - Required

Declaration

 (Required) 1. I declare all information provided in this application form and the attached documents (if any) are, to the best of my knowledge, accurate and complete.

 (Required) 2. I consent to follow the Rules and Regulations of the Centre once I enrol on the Course.

 (Optional) 3. I consent to allow my name and relevant information, including country, specialty, affiliated hospital and dates of course completed, to be published on the website of the CHKC-ACS (www.chkc-acs.org) after successful completion of the course.

Notes

1. Successful applicants will be informed individually and should reply on or before the deadline as specified if they accept the offer. Failure to reply before the deadline will result in cancellation of the admission offer. The enrolled space will then be released to another applicant. Places on the course are non-transferable.

2. Applicants not being contacted 4 weeks before the course commencement should consider their applications being placed on the waiting list.

Check here if you agree to the declaration and notes above.