Npmcn Fellows Recommendation Form 2015

Npmcn.edu. ng REGISTRATION OF ASSOCIATE FELLOWS IN THE FACULTY OF-----------------------------------------------------------------------------A. NATIONAL POSTGRADUATE MEDICAL COLLEGE OF NIGERIA Km 26 Lagos-Badagry Expressway P. M. B. 2003 Ijanikin Lagos Tel* 01-2913110 01-2904523 website www. PERSONAL DETAILS NAME*. Surname Middle name First name HOME ADDRESS*. PROFESSIONAL/INSTITUTION ADDRESS*. PREFERRED POSTAL ADDRESS*. TELEPHONE NO. EMAIL ADDRESS*. DATE OF BIRTH. SEX. MARITAL STATUS. SPOUSE S NAME*. SPOUSE S ADDRESS*. NEXT OF KIN IF DIFFERENT FROM SPOUSE. ADDRESS OF NEXT OF KIN*. B. BASIC MEDICAL EDUCATION University/Medical School*. Dates. Basic Medical Degree. Dates. Pre-Registration Appointments Dates Hospital Department Consultant C. FULL REGISTRATION WITH MEDICAL DENTAL COUNCIL 1. Date of full Registration. 2. Number on full Registration Certificate. D. YOUTH CORPS YEAR Institution Supervising Consultant Primary Posting Community Project E* POST REGISTRATION EXPERIENCE IN CHRONOLOGICAL ORDER Please asterisk those not recognised for Part I. S/N Specialty F* FELLOWSHIP EXAMINATION STATUS G* Faculty Level of Examination Result INSITUTIONAL BASE FOR RESIDENCY TRAINING Name of Institution*. Date Accredited. Accreditation Status Full/Partial Date of Candidate s First Appointment. Status of Candidate on First Appointment. Current Status of Candidate. RECOGNISED POSTINGS COMPLETED Duration H. Posting PAYMENT OF ASSOCIATE FELLOWS REGISTRATION FEES You are required to pay the sum of thirty thousand naira 30 000. 00 only as Associate Fellow Registration fee into Zenith Bank Aguda Branch Account No* 1010778138 sort code 057150437. In addition you will pay Associate Fellows Annual subscription dues from the year you started training till date the annual subscription is ten thousand naira 10 000. 00 per year. This is also to be paid into the above Account Number. The evidence of payment of the above fees are to be attached to the form before forwarding to the College. Payment is expected to be made before 31st of January every year and payment made after 31st of January attracts 100 penalty. I. ASSOCIATE FELLOWSHIP PLEDGE I Dr. do pledge and declare as follows a* To dedicate myself to the preservation and enhancement of the noble ideals and the ethics of Medicine/Dentistry. b. To seek to increase my knowledge and skill by continuing self-instruction by association with specialists of repute and by free exchange of experience and opinion with my teachers and my colleagues at all times and especially in the context of medical care audit. c* To abide by the rules and regulations of the National Postgraduate Medical College of Nigeria and ipso facto by the rules and regulations of the. being a training institution accredited to the said College. Insert the name of the hospital institution Signed J* ATTESTATION I do attest to the truth of the information provided above and have undertaken on behalf of the. hospital to accept Training Programme. Name of Head of Training Department. Department of*. Signature.