Application Form
Name of Applicant: _____________________________ Title: ________________
Unit and Institution: ___________________________________________________
Address: _____________________________________________________________
Telephone: __________________________ Fax: ___________________________
Meeting to be attended: ________________________________________________
Organization of the Meeting: ___________________________________________
Title of the Abstract: __________________________________________________
____________________________________________________________________
Authors of the Abstract: ______________________________________________
____________________________________________________________________
Status of the applicant:
Nephrology trainee / Fellow (Medical Officer) / Nurse / Medical Technologist
Status of membership: Full / Associate
Declaration by the applicant:
I declare that I will not receive any other sponsorship for this meeting if my application is successful.
Signature of Applicant:
______________________________ Date: ________________________
Certification by the head of the Division of Nephrology:
I declare that the above applicant is a Trainee / Fellow (M.O.) / Nurse / M.T. * and I support his/her* application.
___________________________________ Date: ________________________
(Signature) / (Block letters)
Please
submit a copy of the abstract and the letter of acceptance to the Dr. CB Leung,
Member’s Affair, HKSN
C/O:
Department of Medicine and Therapeutics, Prince of Wales Hospital, NT.
*Delete where appropriate
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(For Official Use) Application Result: Approved / Not Approved. Approved amount:________ |