National Medical Research Council

National Medical Research Council

SURGERY ACP COURSE SPONSORSHIP

APPLICATION FORM

  1. Eligibility
The applicant should be:
  1. Should be Clinically qualified (i.e. with MD/MBBS/BDS) and
  2. Should be a Consultant, Associate Consultant, Registrar or Resident under Surgery ACP
  3. Should not be currently receiving any course sponsorship
  4. Should not be applying for any course sponsorship offered by other funding bodies
  1. This Sponsorship will sponsor up to SGD 10,000 per applicant for the proposed course or the entire course fee, whichever is lower.
  1. The following types of courses can be considered for sponsorship:
  1. Local or overseas; and
  2. Master degree and above, and
  3. Related to medicine, research and biostatistics
E.g. Master in Clinical Investigation (MCI), M.Sc., M.Phil, Master in Public Health (MPH)
Examples of courses not eligible for sponsorship:MMed or equivalent, Master in Business Administration (MBA)
  1. The applicant must submit documentary proof of his/her completion of the course to the Surgery ACP Research Office within one month of the completion of the course.
  1. If the awardee does not complete the course, he/she may be asked to refund the sponsorship received to Surgery ACP Research Office.
  1. All information will be treated in confidence. The information is furnished to the Surgery ACP Research Office with the understanding that it will be used for evaluation, reference and reporting purposes only.
  1. Surgery ACP Research Office may request for more information from the applicants in the process of deciding whom to award the sponsorship to.

Instructions to Applicants:
  1. Please read the following instructions carefully before submitting the form. Failure to comply with all the requirements will result in the rejection of your application.
  1. Use Arial font, size 10, single-spaced.
  1. Complete ALL sections in the application. Indicate “NA” wherever applicable.
  1. Attach all relevant documents.
  1. Submission your applications by emailing the followings to Ms Arina ():
  1. Scanned copy of the original signed application form
  1. One softcopy (in word document and as a single file) of the application form
  1. Queries can be directed to Ms Jovin Ho: 65767961 /

1. PERSONAL PARTICULARS

Name: / NRIC / Passport No.:
Email Address:
Contact Numbers / Office:
Mobile:
Department: / Institution:
Qualifications: (Academic & Professional)
Clinical Grade*:Consultant / Associate Consultant / Resident / Registrar
If you are currently a resident, specify the residency programme that you are in:
Are you currently in a formal research programme: (Please tick in the correct box)
Clinician-Scientist track residency programme
Research fellowship programme
Others. Please specify:
Not in a formal research programme

2. DETAILS OF REFEREES

Referee 1 / Referee 2
Name:
Designation / Organisation:
Email address:

3. DETAILS OF PROPOSED COURSE

Please provide documentary proof of the course fee

CourseTitle:
Full time/part time*
/
Local / overseas*
Course fee (in SGD, including GST): / Institution conducting the course:
Duration of Course: ___ month / year*
Start Date: (dd/mm/yyyy) Completion Date:(dd/mm/yyyy)
Why is the course useful / important for you? (Max 100 words)

* delete where appropriate

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4. COURSES ATTENDED & SPONSORSHIPS RECEIVED (E.G. SCHOLARSHIP/AWARD) IN THE LAST TWO YEARS

No. / Course title / Date of course / Course Organizer / Course sponsorship received / Funding Body of Sponsorship
1.
2.
3.
4.

5. PUBLICATIONS IN PEER-REVIEWED INTERNATIONAL JOURNALS

No. / Publication title / Authors / Journal / Vol / Page / Year of publication / PubMed ID
1.
2.
3.
4.

6. CONFERENCE PRESENTATIONS (ORAL / POSTER)

No. / Presentation title / Authors / Conference / Year
1.
2.
3.
4.

7. LOCAL AND INTERNATIONAL AWARDS RECEIVED

No. / Award title / Awarded by / Year
1.
2.
3.

8. PREVIOUS / CURRENT / PENDING GRANTS RECEIVED AS PI

No. / Title / Grant amount / Year awarded / Funding agency
1.
2.
3.

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9. DECLARATION BY APPLICANT

  1. I DECLARE that, to the best of my knowledge, the information I have provided on this form is true, accurate and complete.
  1. I consent to the Surgery ACP Research Office:
  1. Holding and using the data on this application form together with other documents attached for the purpose of administering and reviewing my application.
  1. And that it may request for more information from meor my referees in the process of deciding whom to award the sponsorship to.
  1. I agree that such data may be made available to those who reasonably need to know within the Surgery ACP Research Office and its reviewers.

______Signature of Applicant / ______
Date

10. ENDORSEMENT BY PROGRAMME DIRECTOR (for residents) / HEAD OF DEPARTMENT *

I support the above application for the Surgery ACP Course Sponsorship.

______
Signature
Name: / ______
Date

* Delete where appropriate

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