Sample for Pat – FCFP – College of Family Physicians Singapore

(A) Personal Particulars

Full Name (as per NRIC) *

Family Name *

Nationality *

Others - Nationality *

Sex *

NRIC Number *

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 *

Postal Code - Residential Address *

Telephone (Home)

Mobile Number *

Mobile number will be reflected in the hand book. This is to facilitate correspondences between the faculty and trainees.

Email Address *

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

(B) Practice Information

MCR Number *

Example: M12345E

Practising Certificate Type: *

Full
Conditional

Type of Practice *

Others - Type of Practice *

Practice Address *

Postal Code - Practice Address *

Telephone (Office)

Fax (Office)

Please indicate your preferred mailing address *

Residential Address
Practice Address

(C) Entry Criteria

Is/will be a Collegiate Member of the College of Family Physicians Singapore in year 2022 *

Yes
No

Please give details where relevant

Possess MMed(FM) or MCFP(S) *

Yes
No

Please give details where relevant

Is actively involved or will be involved in teaching Family Medicine and College activities upon enrolment into the FCFPS(S) Programme *

Yes
No

Please give details where relevant

Has embarked on personal professional development related to Family Medicine *

Yes
No

Please give details where relevant

Is in active clinical practice *

Yes
No

Please give details where relevant

(D) Qualifications

Degrees / Diplomas Awarded

Qualification *

Year *

Qualification 2

Year 2

Qualification 3

Year 3

Qualification 4

Year 4

Qualification 5

Year 5

(E) 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) 4

Position Held 5

Department Hospital/Medical Group/Practice 5

From (Month / Year) 5

To (Month / Year) 5

Remarks (If any) 5

(F) Documents Submission

Please upload a copy of your passport-sized photograph *

Click or drag a file to this area to upload.

A recent photograph of yourself

Please upload a copy of your CV *

Click or drag a file to this area to upload.

A copy of your Curriculum Vitae

Please upload a copy of your letter of good standing *

Click or drag a file to this area to upload.

A letter of good standing from a Fellow of the College of Family Physicians Singapore

Please upload a copy of your essay *

Click or drag a file to this area to upload.

An essay of not more than 500 words to the following questions:
     A) Why you wish to take the FMFP training programme
     B) What you hope to achieve at the end of the training process
     C) In what way would you contribute to family medicine after completing your training

Please upload a copy of your completed questionnaire *

Click or drag a file to this area to upload.

You may download a copy of the questionnaire here

(G) DECLARATION

Declaration 1 *

I hereby make an application for the Family Medicine Fellowship Programme 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 enrollment is subjected to the admission criteria and examination eligibility as advised by the College of Family Physicians Singapore, which has the power to impose conditions.

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”.

(H) PAYMENT

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

We accept cheque and cashier's order.
Please mail them to College of Family Physicians Singapore.

Address:
College of Family Physicians Singapore
College of Medicine Building
16 College Road, #01-02
Singapore 169854

Please upload a copy of your Cheque Payment (Front) *

Click or drag a file to this area to upload.

Kindly refer to our cheque sample (front). Please take note of the 6 numbers as shown and enter in the fields below for submission.

Please upload a copy of your Cheque Payment (Back) *

Click or drag a file to this area to upload.

Please write the purpose of the cheque payment at the back of the cheque. In this case, [FCFP(S) 2020 - 2022] should be indicated. You may refer to the cheque sample (back) if you are unsure.

Bank *

Please indicate the issuing bank of your cheque for records purposes.

Cheque Number *

This is the six digit number at the bottom of the cheque.
You may refer to the cheque sample (front) if you are unsure.

Signature *

FELLOWSHIP

FCFP(S) Application Form

(A) Personal Particulars

(B) Practice Information

(C) Entry Criteria

(D) Qualifications

(E) Appointments

(F) Documents Submission

(G) DECLARATION

(H) PAYMENT