SINGHEALTH ALICE LEE INSTITUTE OF ADVANCED NURSING
168, JALAN BUKIT MERAH, SURBANA ONE, #18-01, SINGAPORE 150168
Tel: (65) 6576 2703 / 2702
Email: [email protected] / [email protected]
Course Timing:
Certification: 0800 – 1700hrs
Re-Certification: 0800 – 1300hrs
Course Details
Course Title
Course Date
Course Time
Remarks (if any)
Contact Person
:
:
:
:
Name
:
Org. / Dept
:
Email address
:
Contact No.
:
Participant Details
S/n
Full Name :
Identification No. /
Passport No. :
Department / Designation:
SNB / MCR
No:
Contact No. :
1.
2.
3.
Email Address :
Pre-Requisite (if applicable)
Previous certificate issued from :
SGH-IAN /
Other institution
(Please attach a copy)
SGH-IAN /
Other institution
(Please attach a copy)
SGH-IAN /
Other institution
(Please attach a copy)
Payment Method (Please select one option only)
A confirmation email will be send to you once a place is confirmed & payment details will be advised via email
SGH COST CENTRE: _________________
Attention to:
By CASH
Organization:
(Please write in full)
By CHEQUE (Payable to: “Singapore General Hospital Pte Ltd”)
Department:
By INVOICE
Address:
By INVOICE (MOHH)
- Applicable to doctors attending BCLS course only
Purchase Order
No. (if applicable):
Mailing Address
Attention to:
Address:
By providing the information set out in this form and submitting the same to you, I confirm that I have read, understood and consent to the SingHealth Data Protection Policy, a copy of which is available
at “http://singhealth.com.sg/pdpa”.
Dated: 20 April 2015