Course Application

 
Please complete the Application Form

* Compulsory fields
Course Information
Course Name: [FULL] Certificate Course on Peritoneal Dialysis for Nurses and Allied Health Professionals 2022 (CCPD 2022)
Course Date: 16 Dec (Lecture) and 19 Dec 2022 (Seminar & Workshop)
Course Venue: Lecture Theatre, G/F, HKEC Training Centre for Healthcare Management & Clinical Technology,
Pamela Youde Nethersole Eastern Hospital, 3 Lok Man Road, Chai Wan, HK
Thank you for your interest in CCPD 2022. Please note that the enrollment of CCPD 2022 is overwhelmed, please fill out and submit the form as usual, your application will be placed on the waitlist at this stage; we will notify you by email for follow-up arrangement when a place becomes available. Thank you.
:
:
Remarks:
Personal Details
Title:
 
*Surname: (as appeared on Passport / Identity Card)  
*Given names: (as appeared on Passport / Identity Card)  
*Mailing Address:  
*Country:  
*Email Address: (Confirmation email will be sent to this address)  
Contact Number(s): Office:      *Mobile:  
eLearner ID(HA staff only):  
HKAM Reg. No.:  
 
Career Information
*Professions:  
*Position / Rank:  
*Department / Unit:  
*Institute / Hospital:  
 
Declaration
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.