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Application

HPBA (Singapore) Membership Application Form
Personal Information
Prefix
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First Name *
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Last Name *
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E-mail *
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Date of birth *
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Contact Information

Institution *
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Department *
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Address 1 *
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Address 2 *
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Address 3 *
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Postal Code *
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Telephone *
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Fax
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Primary Speciality *
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If other speciality, please indicate:
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Membership types

                                Entrance Fee    Annual Subscription
Membership Fees *



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Additional Information

Academic or Other Degrees *
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Medical School *
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Graduation Date *
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Further training *
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Engaged in Teaching? *
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Engaged in Research? *
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Present Professional Appointment & Workplace *
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Registered Medical Practitioner with SMC
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Registered Specialist with Specialist Register of MOH
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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
12 West Coast Walk, #02-06
West Coast Recreation Centre
Singapore 127157

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.


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