Application HPBA (Singapore) Membership Application Form Personal Information Prefix DrMrMrsMsProf Invalid Input First Name * Invalid First Name Last Name * Invalid Input E-mail * Invalid email address. Date of birth * Invalid Input Contact Information Institution * Invalid Input Department * Invalid Input Address 1 * Invalid Input Address 2 * Invalid Input Address 3 * Invalid Input Postal Code * Invalid Input Telephone * Invalid Input Fax Invalid Input Primary Speciality * Gastroenterology Radiology Surgery OtherInvalid Input If other speciality, please indicate: Invalid Input Membership types Entrance Fee Annual Subscription Membership Fees * Full Member – S$ 100.00 S$50.00Associate Member – S$ 20.00 S$20.00Affiliate Member – S$ 10.00 S$10.00Life Member – S$ 100.00 S$500.00 (one-time)Invalid Input Additional Information Academic or Other Degrees * Invalid Input Medical School * Invalid Input Graduation Date * Invalid Input Further training * Please list Hospital, City/Country, Dates, and Type (last 3 hospitals if applicable)Invalid Input Engaged in Teaching? * YesNoInvalid Input Engaged in Research? * YesNoInvalid Input Present Professional Appointment & Workplace * Invalid Input Registered Medical Practitioner with SMC YesNoInvalid Input Registered Specialist with Specialist Register of MOH YesNoInvalid Input IMPORTANT NOTE Payment can be made in the following manner: Via cheque issued in favour of " HPBA (Singapore)" and send with the membership application to: HepatoPancreatoBiliary Association (Singapore) c/o Wizlink Consulting Pte Ltd 2 Venture Drive #16-16 Vision Exchange Singapore 608526 Tel: +65 6774 5201 Fax: +65 6774 5203 Please print your name on the back of the cheque Kindly note that the HPBA Executive Committee will not consider your membership application if payment is not received. RefreshInvalid Input
