Certificate in Community Hospital Practice (CCHP) – College of Family Physicians Singapore

(A) Personal Particulars

Full Name (as per NRIC) *

Family Name *

Nationality *

Others - Nationality *

Sex *

Passport / NRIC No *

Your NRIC number is collected only for the necessary purpose of verifying your qualification or medical registration in order to determine whether the College’s admission requirements have been fulfilled.

Date of Birth *//

Race *

Others - Race *

Residential Address *

Residential Address Postal Code: *

Telephone (Home)

Mobile Number *

Email Address (Primary) *

All course information pertaining to the GDFM programme will be sent via email to the provided address. Please ensure that this is the email account you would check regularly.

Email Address (Secondary)

You will be contacted via this email address if we fail to reach you via the primary email address.

(B) Practice Information

Medical Registration Type *

MCR Number *

Example: M12345E

Temporary Registration Number *

Please upload a copy of the Letter of Recommendation *

Click or drag a file to this area to upload.

Application by temporary registered doctors must have at least 1 year of working experience in Singapore and also be supported by a Letter of Recommendation from his/her Head of Department.

Year of SMC Registration *

Year of SMC Registration

Year of Graduation *

Practicing Status *

Resident or Specialty Trainee
Non-Resident
In Service Medical Officer employed by MOHH under MOPEX & still serving bond

Types of Practice *

Others - Types Of Practice *

Practice Address *

Practice Address Postal Code: *

Telephone (Office)

Fax (Office)

Please indicate your preferred mailing address *

Residential Address
Practice Address

(C) Other Information - Degrees / Diplomas Awarded

Degrees / Diplomas Awarded

Qualification *

Year *

Qualification 2

Year 2

Qualification 3

Year 3

Qualification 4

Year 4

Qualification 5

Year 5

Appointments

Position Held *

Department Hospital/Medical Group/Practice *

From (Month / Year) *

To ( Month / Year) *

Remarks (If any)

Position Held 2

Department Hospital/Medical Group/Practice 2

From (Month / Year) 2

To ( Month / Year) 2

Remarks (If any) 2

Position Held 3

Department Hospital/Medical Group/Practice 3

From (Month / Year) 3

To ( Month / Year) 3

Remarks (If any) 3

Position Held 4

Department Hospital/Medical Group/Practice 4

From (Month / Year) 4

To ( Month / Year) 4

Remarks (If any)

Position Held 5

Department Hospital/Medical Group/Practice 5

From (Month / Year) 5

To ( Month / Year) 5

Remarks (If any) 5

(D) Documents Submission

Please upload a copy of passport-sized photograph *

Click or drag a file to this area to upload.

Please upload a copy of your NRIC / Employment Pass (Front) *

Click or drag a file to this area to upload.

Please upload a copy of your NRIC / Employment Pass (Back) *

Click or drag a file to this area to upload.

Please upload a copy of CV *

Click or drag a file to this area to upload.

I am *

Please upload a copy of GDFM certificate (for GDFM graduates) *

Click or drag a file to this area to upload.

Please upload a copy of GDFM Course acceptance letter (for GDFM trainees) *

Click or drag a file to this area to upload.

(E) APPLICATION FOR SUBSIDY

I am applying for the Certificate in Community Hospital Practice Subsidy *

Yes
No

If No, please complete section (F) & (I) Payment below.
If Yes, please complete sections (F), (G), (H) & (I) Payment below.

Please take note that the availability of the subsidy is subjected to confirmation by MOH at a later date.

(F) DECLARATION

Declaration 1 *

I hereby make an application for the Certificate in Community Hospital Practice and declare that all the information I have supplied on this application form is, to the best of my knowledge, complete and correct.

Declaration 2 *

I acknowledge that my application for enrolment is subjected to the admission criteria and examination eligibility as advised by College of Family Physicians Singapore.

Declaration 3 *

I confirm and consent to College of Family Physicians Singapore collecting, using and/or disclosing my personal data which I have provided, including the NRIC Number.

Declaration 4 *

I further acknowledge that by signing this, I have read and agreed to abide by the Terms & Conditions as stated under “Important Notes”.

(G) Declaration for the Certificate in Community Hospital Practice Subsidy

Declaration 1 *

I hereby make an application for the Certificate in Community Hospital Practice Subsidy and declare that all the information I have supplied on this application form is, to the best of my knowledge, complete and correct.

Declaration 2 *

I acknowledge that my application for enrolment is subjected to the admission eligibility criteria for the Certificate in Community Hospital Practice programme, examination and the Certificate in Community Hospital Practice Subsidy as advised by CFPS and MOH respectively.

Declaration 3 *

I acknowledge that by signing this, I have read and agreed to abide by the Terms & Conditions as stated under “ CCHP Subsidy Important Notes”.

Declaration 4 *

I declare that I do not have any disciplinary record with the SMC.

(H) Letter of Undertaking for the Certificate in Community Hospital Practice Subsidy

Subsidy Declaration 1 *

I hereby confirm my acceptance of the Terms and Conditions as spelled out by the Ministry of Health regarding the Certificate in Community Hospital Practice Subsidy as stated in the Important Notes section of this Application Form.

Subsidy Declaration 2 *

I affirm that all statements made by me in the application form are correct. I understand that in the event that I am unable to satisfy any one of the eligibility criteria of this Certificate in Community Hospital Practice Subsidy, I will refund the entire subsidy in accordance with the terms and conditions.

Subsidy Declaration 3 *

I acknowledge that the decisions of the Administrator of Certificate in Community Hospital Practice Subsidy shall be final and any appeals must be made in writing to the Administrator who will then forward it to the Ministry of Health for further consideration.

(I) Payment

Registration Fee: $214 (inclusive of 7% GST)

Registration Fee is non-fundable.
Payment is via PayNow only.

PayNow UEN: S71SS0039J

Key in your MCR No. and Name under the UEN/Bill Reference No.

Please upload a screenshot of your PayNow Payment *

Click or drag a file to this area to upload.

PayNow to UEN: S71SS0039J

Bank *

Account Number *

Date of Transaction *

Account Holder Name *

Signature of Applicant *

CERTIFICATE IN COMMUNITY HOSPITAL PRACTICE

CCHP Application Form

Please note that only GDFM Graduates or Current/New GDFM trainees are allowed to apply for the Certificate in Community Hospital Practice

(A) Personal Particulars

(B) Practice Information

(C) Other Information - Degrees / Diplomas Awarded

Appointments

(D) Documents Submission

(E) APPLICATION FOR SUBSIDY

(F) DECLARATION

(G) Declaration for the Certificate in Community Hospital Practice Subsidy

(H) Letter of Undertaking for the Certificate in Community Hospital Practice Subsidy

(I) Payment