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Hong Kong College of Emergency Medicine (HKCEM)

Intermediate Examination in Emergency Medicine (IEEM)

Application Form

Ø  Please complete by using the word file (recommended) or write in block letters with black ball pen.

Ø  All certified true copies of documents must be certified by the respective Training Supervisor or Consultant.

Ø  Please enclose this application form with 1 set of all certified true copies.

Personal Information:

Please enclose 2 Photographs with name written at the back.

Surname
(Family Name)
(same as ID Card) / Forename
(Given Name)
(same as ID Card)
Chinese Name
(if applicable) / Sex # / Male / Female / Date of Birth
(day/month/year)

# Please delete where inappropriate.

Present Appointment:

Please enclose certified true copies of License of Registration (for first attempt candidate only) and Annual Practicing Certificate of Hong Kong Medical Council (HKMC). (* note 1 – see below for non-HK applicant)

Rank / Department
Hospital / HKMC Registration No.

Contact Information:

Priority
(1, 2…) / * At least one number must be provided. / Priority
(1, 2…) / * At least one address must be provided.
Office* / Office Address*
Home*
Mobile* / Home Address*
Pager*
Fax
(if applicable) / Other Address*
(if applicable)
Email Address
(Essential item)

Relevant Degrees and Qualifications:

Please enclose certified true copies of Relevant Degrees. (* note 2)

Qualifications / Awarding Institutes / Date conferred
(day/month/year) / Remark /

* Note 1: Non-HK applicant MUST provide documented proof of license of registration (or equivalent) AND proof of eligibility to practice in his/her country of practice.

* Note 2: For re-sit candidate, please only submit certified true copies of relevant degrees obtained AFTER last attempt.

Training Requirement:

Please enclose certified true copies of Training Certification Letters. (* note 3)
Please complete in chronological order from internship to the current post.

Starting Date
(day/month/year) / Ending Date
(day/month/year) / Duration
(months / years) / Hospital / Department / Rank / Certification
letter
(appendices) /
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S

* Note 3: Training Certification Letter for internship training is not required. For re-sit candidate, please only submit certified true copies of Training Documents for the period after the application date of last application.

Examinations passed:

Please enclose certified true copies of the relevant Examination Results (PEEM or equivalent).

Examinations / Awarding Institutes / Date conferred
(day/month/year) / Remark /

For re-attempt applicants, please enclose certified true copy of the last Examination Results.

Have you previously attempted the IEEM of HKCEM or Part B/C of MCEM? # / Yes / No
Exam. No. of the last Exam
(if applicable) / Date of the last Exam
(day/month/year)

# Please delete where inappropriate.

Payment

Exam Fee: HK$15,000 for Full Examination / HK$7,000 for Re-sit Part 1 / HK$8,000 for Re-sit Part 2
The cheque is payable to “Hong Kong College of Emergency Medicine”.

Receipt will be issued with the Admission Note.

Part of Exam attended # / Full Examination /
Re-sit Part 1 /
Re-sit Part 2 / Cheque Number / Bank

# Please delete where inappropriate.

Signature of Applicant / Signature of Training Supervisor or Deputy
Name of Applicant / Name of Training Supervisor or Deputy
Date of Application / Date of Endorsement

Revised on 4 October 2012 Page 1 of 3