Course Information
Course Name:   Course Date:   Course Fee:
Personal Details
Title: ProfessorDr.Mr.Mrs.Ms.Miss   *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:
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".
I declare that I have read and confirm the above declaration                    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.