Course Application

Please complete the Application Form, and send us a crossed cheque in respect of the course fee payable to
"Hospital Authority"
to the following address:
Room 75, 2/F, Main Block
Department of Intensive Care
Pamela Youde Nethersole Eastern Hospital
3 Lok Man Road
Chai Wan, Hong Kong
( Attn: Ms Candice LAW )

* Compulsory fields
Course Information
Course Name: The 16th Critical Care Nephrology Course (CCNC16)
Course Date: 26 Mar 2019 (Lecture) and/or 12 Apr 2019 (Workshop)
Course Fee (After 15 Mar 2019):
: 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:  
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.