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College Membership 2020
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(A) Personal Particulars
Full Name (as per NRIC)
Family Name/Surname
Nationality
Singaporean
Singaporean PR
Others - Please Specify
Others - Nationality
Gender
Male
Female
Third Choice
Passport / NRIC No
Date of Birth (dd/mm/yyyy)
MM
1
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/
DD
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YYYY
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2020
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1927
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1922
1921
1920
Race
Chinese
Malay
Indian
Others - Please Specify
Others - Race
Residential Address
Postal Code
Telephone (Home)
Mobile Phone
Email Address
(B) Practice Information
MCR No
Please specify practising certificate type:
Full
Conditional
Types of Practice
Goverment
NHG
Singhealth
Private - Group
Private - Solo
Locum
Practice Address
Postal Code
Telephone (Office)
Fax (Office)
Please indicate your preferred mailing address
Residential
Practice Address
(C) Medical Education
Medical School
Degree
Year of Graduation
Other Qualification and Diplomas
Single Line Text
Postgraduate Experience & Training
Position Held
Hospital/Institution
Country/City
From ( mm/yyyy) To (mm/yyyy)
Single Line Text
Single Line Text
Single Line Text (copy)
Single Line Text
Single Line Text
Single Line Text (copy)
Single Line Text (copy) (copy)
(copy)
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(copy) (copy) (copy) (copy) (copy) (copy) (copy)
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(copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
Are you now engaged in active family practice?
Yes
No
Family Practice
Position Held
Organisation
From (mm/yyyy) To (mm/yyyy)
Single Line Text
Single Line Text
Single Line Text (copy)
Single Line Text
Single Line Text
Single Line Text
Single Line Text
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DECLARATION
I hereby make an application for membership in the College of Family Physicians Singapore and declare that the information stated in this application is true and correct and I have not withheld/distort any facts.
I understand that the money will be refunded if my application is not approved.
In submitting this application, I hereby agree to abide by the regulations of the College of Family Physicians Singapore.
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.
Cheque Number
*
Cheque Amount
*
Signature
Clear Signature
Date
Notes
Admission to Associate or Ordinary membership category is based on the recommendation made by the Board of Censors; subject to the approval of the College's Council at the monthly Council Meeting.
Fees (Inclusive of 7% GST)
Entrance Fee: S$53.50 one time payment
Associate/Ordinary membership fees:
S$192.60 per financial year (1st Apr - 31st Mar)
S$96.30 per half financial (for new members joining during 2nd half of financial year, 1st Oct - 31st Mar)
Student membership fees: NIL
Please send the completed application form (with photograph attached) together with a cheque payment, make payable to '
College of Family Physicians Singapore
' to
The Honorary Secretary
College of Family Physicians Singapore
College of Medicine Building, 16 College Road #01-02 Singapore 169854
FOR OFFICIAL USE ONLY
Recommended for Associate / Ordinary / Student Membership
Signature
Clear Signature
Censor-In-Chief
Date
Name
Submit
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