Course Application

Please complete the Application Form, and send us a crossed cheque in respect of the course fee payable to
"Hong Kong Society of Robotic Surgery Ltd."
to the following address:
Room 019, 2/F, Main Block
Pamela Youde Nethersole Eastern Hospital
3 Lok Man Road
Chai Wan, Hong Kong
( Attn: Ms. Gloria KWOK )

* Compulsory fields
Course Information
Course Name: 3rd Endocrine and Head & Neck Symposium
Course Date: 03 May 2019 - 04 May 2019
Course Fee:

Welcome Dinner (6:30pm, 3 May 2019) United Services Recreation Club, 1 Gascoigne Road, King’s Park, Kowloon:
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:  
eLearner ID(HA staff only):  
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.