1.MY PARTICULARS:
1.1 Name in full *
(as in NRIC or passport )		 :
1.2
a. NRIC Number (for Malaysian) *
:
New : (without " - " )
 
b. Passport No.*
(for Non-Malaysians)
: (for Malaysian :"-" if dont have passport No)
1.3 Contact Number * : (without " - " )
   Gender* :

1.4 Email Address * :
1.5 Home Address * :
Full Address
  Postal Code :
1.6 Postal Address * :
Full Address
1.7 Next of Kin* :
  Address of Next of Kin* :
Full Address
  Postal Code :
2. MY ACADEMIC BACKGROUND :
2.1 Name of parent medical school* :
2.2 Address of parent medical school :
2.3 Year of study :        
2.4 Expected year of graduation :        
2.5 Indicate briefly your clinical experience to date, if any :        
 
Date Disciplines Duration(week)
   
   
   
   
3. THE PARTICULARS OF ELECTIVE POSTING REQUESTED :
3.1 Hospital* :
  Period of Elective Posting *:
 
From :
(format date: mm/dd/yy) 		  To :
(format date: mm/dd/yy)
(Total = weeks )
( The total length of the posting should not exceed six weeks. The minimum time spend in any particular discipline should not be less than three weeks)
3.2 My Preferred Postings * :
  Please indicate not more than three disciplines in terms of preference :
  a .
  b .
  c .
  NOTE : The authority has the right to determine any postings without reference to your application.
4. HEREWITH I ENCLOSE :
a. Certified photocopy of my identity card (for Malaysian) or passport (for foreigners); and
b. Supporting document/s from the Dean.
   
5. DECLARATION :
I do hereby solemnly declare that :
a. all the particulars stated above are correct;
b.

I have read and understand the provisions regarding thelective posting and agree to abide by and be governed by all the rules now in
effect or as announced hereafter from time to time; and [KKM Guidelines]
c. I hereby agree to give an undertaking not to hold the hospital , clinic or the Ministry of Health responsible for any injury or mishaps sustained during the tenure of my posting.
   
  Thank you.
  Date :
 
  Please complete this form and return to the respective State Health Department or Institution and attach a letter from your institution requesting for the elective posting.


HOMEPAGE / LAMAN UTAMA