Course Application

Please complete the Application Form, and send us a crossed cheque in respect of the course fee payable to
"Hong Kong Society for Coloproctology Ltd. " to the following address:
Department of Surgery
Pamela Youde Nethersole Eastern Hospital
3 Lok Man Road, Chai Wan, Hong Kong
( Attn: Ms. Gloria KWOK  )

* Compulsory fields
Course Information
Course Name: 19th Digestive Endoscopy Course
Course Date: 18 Aug 2017
Course Fee:

: Free of Charge
Personal Details
*Given names: (as appeared on Passport / Identity Card)  
*Mailing Address:  
*Email Address: (Confirmation email will be sent to this address)  
Contact Number(s): Office:      *Mobile:  
Career Information
*Position / Rank:  
*Department / Unit:  
*Institute / Hospital:  
I declare that the particulars in this application are true to the best of my knowledge and belief, and I have not wilfully suppressed any material facts.  Any misrepresentation or omission of information will be grounds for withdrawal of acceptance for the application.  I have also read and understood the information about "the Notice to Applicant - Personal Data".
Please note that the above contact details will not be used for unsolicited e-mail or be sold to third parties without the user's consent.