FAS Application

This form may take you 20 minutes to complete. Please ensure that you have the following documents/information with you before filling up the online form:
1. Identity Card / Passport
2. Details of Undergraduate Medical Qualifications
3. Details of Postgraduate Medical Qualifications
4. TOEFL or IELTS score, if any
5. History of Work Experience
6. Details of 2 Referees

KK Fellowship Application Form

(I) Type Of Programme

Discipline

Programme Name

Sponsorship Sponsored by your hospital/self/third parties Not sponsored

Period of Training

If others, please specify

With Hands-On Yes No

State Training Objectives
(max 500 characters)

(II) Particulars of Applicant

Full Name as shown in Identity Card / Passport

Contact Number

Email

Identity Card / Passport Number

Sex
Male Female

Date of Birth

Marital Status

(III) Qualifications of Applicant

Undergraduate Medical Qualifications

Category

Institution

Country

Date of Joining

Date of Completion

Qualification Attained

Year Attained

Pre-Medical Degree (where applicable)

Undergraduate Medical Degree

Details of Undergraduate Medical Degree

If you DID NOT complete your undergraduate medical degree in the SAME university, please check below box and complete the following section

   Did Not Complete Degree in the Same University

First Year

Second Year

Third Year

Fourth Year

Fifth Year

Sixth Year

Postgraduate Medical Qualifications

Postgraduate Qualification

Conferring Institution

Country

Speciality

Year

Was your medical training conducted in English?                                 Yes No

TOEFL score (if any)

IELTS score (if any)

(IV) Work Experience of Applicant

Internship / Housemanship Experience

Discipline

Date of Joining

Date of Completion

Institution

Country

Appointment

Please list in chronological order from the most recent appointment:

Position Held

Date of Joining

Date of Completion
Department / Institution
Country

(V) Referees

Particulars of 2 referees who are at least of consultant grade and members of the academy of medicine or recognised foreign academic / professional organisations

First Referee

Name

Occupation and Designation

Name and Place of Employment

Contact Number

Email

Facsimile Number

In What Capacity Do You Know Him/Her

Number of Years You Know Him/Her

Second Referee

Name

Occupation and Designation

Name and Place of Employment

Contact Number

Email

Facsimile Number

In What Capacity Do You Know Him/Her

Number of Years You Know Him/Her

(VI) Declaration by Applicant

Have you ever been or are you currently the subject of an inquiry or an investigation by any licensing or health authority in Singapore or elsewhere involving an allegation of professional misconduct or any improper conduct which brings disrepute to the medical profession? Yes No

If yes, please specify reason(s)

Have you ever suffered or are you suffering from any physical or mental illness which impairs your fitness to practise as a medical practitioner? Yes No

If yes, please specify reason(s)

Are you a hepatitis B carrier? Yes No

Have you ever been convicted in a court of law in Singapore or elsewhere of any offence? Yes No

If yes, please specify reason(s)

I declare that the information I am submitting are true and complete to the best of my knowledge, and that I have not willfully suppressed any material fact.

KK Fellowship Application Form

(I) Type Of Programme
Discipline
Programme Name
Sponsorship	Sponsored by your hospital/self/third parties Not sponsored
Period of Training
If others, please specify
With Hands-On	Yes No
State Training Objectives (max 500 characters)

(II) Particulars of Applicant
Full Name as shown in Identity Card / Passport
Contact Number	Email
Identity Card / Passport Number	Sex	Male Female
Date of Birth	Marital Status

(III) Qualifications of Applicant

Undergraduate Medical Qualifications

Category	Institution	Country	Date of Joining	Date of Completion	Qualification Attained	Year Attained
Pre-Medical Degree (where applicable)
Undergraduate Medical Degree
Details of Undergraduate Medical Degree	If you DID NOT complete your undergraduate medical degree in the SAME university, please check below box and complete the following section Did Not Complete Degree in the Same University
First Year
Second Year
Third Year
Fourth Year
Fifth Year
Sixth Year
Postgraduate Medical Qualifications
Postgraduate Qualification	Conferring Institution		Country	Speciality		Year





Was your medical training conducted in English? Yes No
TOEFL score (if any)
IELTS score (if any)

(IV) Work Experience of Applicant
Internship / Housemanship Experience

Discipline	Date of Joining	Date of Completion	Institution	Country





Appointment
Please list in chronological order from the most recent appointment:
Position Held	Date of Joining	Date of Completion	Department / Institution	Country

(V) Referees

Particulars of 2 referees who are at least of consultant grade and members of the academy of medicine or recognised foreign academic / professional organisations
First Referee
Name
Occupation and Designation
Name and Place of Employment
Contact Number
Email
Facsimile Number
In What Capacity Do You Know Him/Her
Number of Years You Know Him/Her

Second Referee
Name
Occupation and Designation
Name and Place of Employment
Contact Number
Email
Facsimile Number
In What Capacity Do You Know Him/Her
Number of Years You Know Him/Her

(VI) Declaration by Applicant

Have you ever been or are you currently the subject of an inquiry or an investigation by any licensing or health authority in Singapore or elsewhere involving an allegation of professional misconduct or any improper conduct which brings disrepute to the medical profession?	Yes No
If yes, please specify reason(s)
Have you ever suffered or are you suffering from any physical or mental illness which impairs your fitness to practise as a medical practitioner?	Yes No
If yes, please specify reason(s)
Are you a hepatitis B carrier?	Yes No
Have you ever been convicted in a court of law in Singapore or elsewhere of any offence?	Yes No
If yes, please specify reason(s)