HONG  KONG  DOCTORS  UNION

Room 901, Hang Shing Bldg., 363-373, Nathan Road, Kowloon

E-mail: hkdu@hkdu.org   Home Page: http://www.hkdu.org   Tel. no.: 2388 2728   Fax no.:2385 5275

To      :  All Members                              This Circular is restricted to HKDU members only

From    :  Dr. Lam Ying Ming, Chairman, Committee on CME             Circular No. 0015, 7th June, 2002

Registration Form (報名表格)

香港西醫工會延續醫學進修證書計劃

HKDU CME Programme for the year from 1.7.2002 to 30.6.2003

(Please tick)

1.   □    本人現申請參加由1.7.2002至30.6.2003的香港西醫工會延續醫學進修證書計劃，並同意遵守該計劃之規章。  I would like to join the HKDU CME Programme for the year from 1.7.2002 to 30.6.2003 and agree to abide by the rules and regulations for the award of certificate of continuing medical education as prescribed by the Union from time to time.

2.   □  I am interested in joining the accredited CME functions of the following HKDU Study Group(s) marked with a tick. Please ask the Study Group Coordinator(s) to send me the details of the future CME functions.

□         Wanchai              □ Causeway Bay        □ Hong Kong East        □ Sham Shui Po        □         Kwai Tsing   

□         Tsuen Wan          □ Tuen Mun        □ Shatin         □ Tai Po        □         Sheung Shui       

□         Tseung Kwan O        □ Kwun Tong        □ Hung Hom        □ Wong Tai Sin        □        Baptist Hospital□         Mong Kok

3.   □    本人現選擇香港西醫工會為本人於香港醫務委員會延續醫學進修計劃之唯一行政機構。本人明白香港西醫工會是免費為本人處理於香港醫務委員會延續醫學進修計劃之事宜。

(若您已選擇香港西醫工會為您於香港醫務委員會延續醫學進修計劃之唯一行政機構,無須再選擇第三點。)

I now select the HKDU as my sole CME Programme Administrator under the MCHK CME Programme. I UNDERSTAND THAT NO REGISTRATION FEE IS REQUIRED FOR CHOOSING HKDU AS MY CME PROGRAMME ADMINISTRATOR UNDER THE MCHK CME PROGRAMME.

(If you have already selected HKDU as your sole CME Programme Administrator under the MCHK CME Programme, you do not need to tick Point No. 3.)

 

姓名

    
 

Name                                                        :

(English)

(中文)
 

香港身分證號碼

    

香港醫務委員會註冊號碼

    
 

HKID Card No.

:

  

Medical Council Reg. No.

:

  
       

專科資格 （如適合）

    
 

專業資歷

Professional Qualifications

:

  

Registered Specialty

(if applicable)

:

  
 

工作地址

    
 

Office Address                                                                                :

    
 

辦公室電話號碼

    

傳真號碼

    
 

Office Tel No.

:

  

Fax No.

:

  
 

手提電話/傳呼機號碼

    

電郵地址

    
 

Mobile phone/Pager No.

:

  

E-mail Address

:

  
 

你是否香港西醫工會會員？

  

  □ Yes 是

如是，請填寫你的會員號碼

    
 

Are you a member of HKDU?

:

  □ No 否

If yes, please provide your HKDU Membership No.

:

  
     
     
     

Date 日期

  

Signature of applicant 申請人簽署

請將填妥的申請表傳真至2385-5275 或 2384-9861或寄回香港西醫工會。

Please complete this form and return it by fax at 2385-5275 or 2384-9861 or by post to HKDU as soon as possible.

Personal Data Policy

Personal data is collected for the purpose of the administration of the HKDU CME programme and communication between the Hong Kong Doctors Union and the data subject, who is at liberty to correct/update information as and when necessary. Requests for access to data or correction of data  should be directed to the address above.

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