CONFIDENTIAL

APPLICATION FORM
PAEDIATRIC MEDICINE EXAMINATION
17 AUGUST 2013
1.  PERSONAL PARTICULARS
(Please use CAPITAL LETTERS for this section)
(Please provide a certified true copy of your NRIC (for Singaporeans and PR) or passport (for foreigners) as a supporting document for your application.) / Please provide one (1)
recent passport-sized photo.
Thank you.
Full Name:
(As Per NRIC/Passport) / CLICK TO ENTER TEXT
(Please Underline Surname Or Family Name)
Home Address: / CLICK TO ENTER TEXT
Mailing Address:
(If Different From The Above) / CLICK TO ENTER TEXT
Nationality: / CLICK TO ENTER TEXT / NRIC / Passport No.:
(NRIC For Locals And PR, Passport For Foreigners) / CLICK TO ENTER TEXT
(NRIC / Passport Number*)
Date of Birth: / CLICK TO ENTER TEXT / Gender: / CHOOSE ITEMMALEFEMALE
(DDMMYYYY)
Contact Number (Office): / CLICK TO ENTER TEXT / Contact Number
(Mobile): / CLICK TO ENTER TEXT
Contact Number
(Home): / CLICK TO ENTER TEXT
Email Address: / CLICK TO ENTER TEXT
2.  ACADEMIC QUALIFICATIONS
Basic Medical Degree / CLICK TO ENTER TEXT / CLICK TO ENTER TEXT
Name Of University / Medical School / Country Of Issue
CLICK TO ENTER TEXT / CLICK TO ENTER TEXT
Qualification Attained / Date Issued
(MMYYYY)

“*” Please delete where not applicable.

3.  REGISTRATION AS A QUALIFIED MEDICAL PRACTITIONER
(Please provide a certified true copy of your current Practising Certificate issued by the Singapore Medical Council as a supporting document for your application.)
Registration With Singapore Medical Council: / CHOOSE ITEMFULLCONDITIONALPROVISIONALTEMP / CLICK TO ENTER TEXT / CLICK TO ENTER TEXT
Type Of Registration With SMC / Year Of Registration / MCR Number
4.  RESIDENCY PROGRAM
Sponsoring Institution (SI) / CHOOSE ITEMSINGAPORE HEALTH SERVICES (SINGHEALTH)NATIONAL HEALTHCARE GROUP (NHG)NATIONAL UNIVERSITY HOSPITAL SYSTEM (NUHS)
Current Training Hospital / Healthcare Institution / CLICK TO ENTER TEXT
Residency Program / CLICK TO ENTER TEXT / CLICK TO ENTER TEXT
Start Date
(MMYYYY) / Current Year of Training
5.  DISABILITY / SPECIAL ACCOMMODATION
Candidates with disability or special needs, and require special accommodation during an examination, must submit to MOH a written request with supporting documents no later than the examination registration deadline. Please refer to the Bulletin Of Information for further details.
I would like to apply for special accommodation during the examination.
6.  ENDORSEMENT OF CANDIDATE’S EXAM APPLICATION BY RESIDENCY PROGRAM DIRECTOR
I confirm that the candidate has / will have completed 30 months of Pediatric Medicine postings at the time of the exam sitting.
I attest to the candidate’s good standing and clinical performance, having assessed the candidate’s competence and performance in the six (6) general competencies (professionalism, patient care and procedural skills, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, systems-based practice).
Name of Program Director: / CLICK TO ENTER TEXT
Designation: / CLICK TO ENTER TEXT
Sponsoring Institution: / CLICK TO ENTER TEXT
Signature of Program Director / Date
(DDMMYYYY)
7.  PAYMENT DETAILS
Mode of payment: Only cheque / cashier’s order is accepted
Cheque / Cashier’s order should be made payable to the “Ministry of Health”. Please indicate your name and contact number on the back of the cheque / cashier’s order. Post-dated cheque is not acceptable.
Description / Cheque / Cashier’s order No. / Amount (SGD)
Application and Examination Fees / CLICK TO ENTER TEXT / $450.00
8.  DECLARATION
I affirm that all statements made by me on this form are correct. I understand that any inaccurate or false information (or omission of material information) will render this application invalid and that, if admitted on the basis of such information, I can be required to withdraw from the examination.
I agree to indemnify, release, and hold harmless the Ministry of Health (MOH), ABMS Singapore, LLC (ABMS-S), ABMS International, LLC (ABMS-I), the American Board of Medical Specialties (ABMS) and its Member Boards, and each of its/their respective employees, officers, directors, members and agents, and those furnishing information about me to MOH from any claims, liability, or damage by reason of any of their acts or omissions, done in good faith, in connection with this application; information furnished to or by or on behalf of MOH or ABMS-S; the evaluation of my qualifications; the examination; the enforcement of Policies and Procedures for Certification included in the Bulletin of Information for the Pedatric Medicine Examination, as well as all rules set forth in the website (http://www.oma.gov.sg), as they may be amended from time to time; and any other action taken with respect to any certification granted (or denied, except for the remedy provided in the next sentence with respect to or denial) by MOH, and any assistance provided by ABMS-S, ABMS-I, ABMS or any Member Board to MOH, the Specialists Accreditation Board (SAB), the Joint Committee on Specialist Training (JCST), the Singapore Medical Council (SMC) or any other entity involved in the matters contemplated by this Pediatric Medicine Examination Bulletin of Information. If, for any reason, a candidate is inappropriately denied certification by reason of the acts or omissions of MOH, ABMS-S, ABMS-I, ABMS or any Member Board (including by reason of problems occurring in the creating, administration and scoring of the examinations, such as by reason of power failures, hardware and software problems, human errors), re-examination or re-score shall be the candidate’s sole remedies.
I understand that my examination performance, training program evaluations and other information may be used for policy development and research purposes, including collaboration with other research investigators and scientific publications. For such purposes, the identity of specific individuals, hospitals, or training institutions will not be disclosed.
Signature of Applicant / Date
(DDMMYYYY)

Please send the completed application form together with the supporting documents and payment, before closing date, to

Ministry of Health

College of Medicine Building

16 College Road

Singapore 169854

Attn: Examination Secretariat

Email:

THE PLEDGE FOR PROFESSIONAL CONDUCT FOR EXAMINATIONS

I, understand that by applying, I am entering into a contract with the Ministry of Health (MOH) to take the Pediatric Medicine Examination.
I agree to be bound by the terms, conditions, and rules set forth in the Pediatric Medicine Examination (Ped Examination) Bulletin of Information and the website (http://www.oma.gov.sg), as they may be updated from time to time.
I, understand that that all materials are protected by the Singapore Copyright Act (Cap 63) and the U.S. federal Copyright Act, 17 U.S.C. § 101, et seq. I further understand that the examinations are trade secrets and are the property of the American Board of Pediatrics (ABP) or ABP together with ABMS Singapore, LLC (ABMS-S) with content licensed to MOH for the purposes of conducting the examination. Access to all such materials, as further detailed below, is strictly conditioned upon agreement to abide by the respective Copyright Acts and to maintain examination confidentiality.
I understand that the examination is confidential, in addition to being protected by all applicable laws protecting copyright and trade secrets. I agree that I will not directly or indirectly copy (including by the taking of pictures), reproduce, adapt, disclose, solicit, use, review, consult or otherwise transmit in any manner the examination, in whole or in part, before or after taking my examination, by any means now known or hereafter invented of any kind or nature. I further agree that I will not directly or indirectly reconstruct examination content from memory, by dictation, or by any other means now known or hereafter invented of any kind or nature or otherwise discuss or otherwise communicate examination content with others. I further acknowledge that disclosure or any other use or other communication of the examination content constitutes professional misconduct, copyright infringement and breach of contract, and may expose me to criminal as well as civil liability, and may also result in the imposition of penalties against me, including but not limited to, invalidation of examination results, exclusion from future examinations, suspension, revocation of certification, and other sanctions.
I understand that Pearson VUE is empowered by MOH, ABMS-S and ABP to ensure that the examination is conducted ethically, and that the Pearson VUE test administrators are required to report to ABMS-S and MOH any candidate who exhibits irregular or improper behavior as described in the bulletin of information.
I understand that all irregularity reports will be investigated by MOH and ABMS-S. Irregular or improper behavior in examinations that is observed, made apparent by data forensics, statistical analysis, or uncovered by other means will be considered a subversion of the certification process and will constitute grounds for invalidation of my examination. In addition, MOH may at its discretion suspend or revoke certification, exclude me from future examinations, and inform program director(s), licensing bodies, or law enforcement agencies of MOH’s actions.
I understand that if I need to leave the room or if I have questions at any time during the testing experience, I would need to raise my hand for a Testing Administrator to assist me. I understand that the Administrator will not answer exam-specific questions.
I pledge to comply with the instructions of test administrators and with all rules of this examination.
I confirm that the information provided in my application to MOH is true and correct.
I, agree to the above statements and AGREE TO BE LEGALLY BOUND BY THE FOREGOING.
Signature of Applicant / Date
(DDMMYYYY)
FOR OFFICIAL USE ONLY
Receiving Secretariat / CLICK TO ENTER TEXT
Name / Signature / Date
(DDMMYYYY)
Checklist: / Certified true copies of NRIC (for locals and PR) or Passport (for foreigners)
Certified true copy of valid Practising Certificate from the Singapore Medical Council
Training as a Pediatric Medicine Resident in R3 (at time of exam sitting)
Attestation of the candidate’s good standing and clinical performance ratings by the relevant Program Director
Valid cheque
Acceptance of Declaration & Pledge
Status of Application: / Qualified / Not Qualified / To be Confirmed / Withdrawn*

Page 5 of 5