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: 7th International Endolaparoscopic Surgery Symposium (IESS)
Course Date: 06 Dec 2019 - 07 Dec 2019
Course Fee:

Welcome Dinner (7:00pm, 6 Dec 2019) Sea King Garden Restaurant, 39 Hoi Pong Road Central, Lei Yue Mun:
Personal Details
Title:  
*Surname:  
*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):  
 
Career Information
*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.