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Nov 19, 2013 ... THE UNIVERSITY OF HONG KONG. LI KA SHING FACULTY OF MEDICINE. Department of Pharmacology and Pharmacy. Application Form for ...

THE UNIVERSITY OF HONG KONG LI KA SHING FACULTY OF MEDICINE Department of Pharmacology and Pharmacy Application Form for Intensive Certificate Course on Cardiovascular, Diabetes & Renal Diseases 2013 The personal data provided in this form will be used for processing your application for enrolment on the relevant courses by the administrative and academic departments concerned. If you wish to access or correct your personal data after submission of this form, please contact the Department of Pharmacology and Pharmacy. An attendance certificate will only be issued to students who have attended 100% of the teaching sessions of each of their chosen courses. Date Nov 16, (Saturday) Nov 17, (Sunday)

Time 2013 14:00 - 18:00

2013 19:00 - 22:00

Topic Teacher Cardiovascular, Diabetes & Renal Dr Christina Haaf Diseases Cardiovascular diseases & other Dr Christina Haaf Endocrinological disorders Cardiovascular diseases & other Dr Christina Haaf Endocrinological disorders Renal Diseases Prof Alan Lau

2013 19:00 - 22:00

Renal Diseases

2013 10:00 - 13:00 14:00 - 17:00

Nov 18, (Monday) Nov 19, (Tuesday)

Prof Alan Lau & Dr Christina Haaf

Course fee: $4,000 for the whole session and $2,500 for the weekend session. This form should be completed and returned to the Department of Pharmacology and Pharmacy (L2-55, Laboratory Block, 21 Sassoon Road, Hong Kong) together with a Hong Kong dollar cheque for the course fee, which must be crossed and drawn in favour of "The University of Hong Kong". For enquiries, please contact the General Office (Tel: 2819 9460; Fax 2817 0859; email: [email protected]). Section A 1.

PERSONAL INFORMATION Dr/Mr/Mrs/Miss*__________________________________________ (Full name in block letters, as in your HKID Card/ passport [surname first]) Name in Chinese (if any): ___________________________________

Correspondence Address: _______________________________________________________________ ____________________________________________________________________________________ Fax No.: ______________________ Tel. No.: ______________________ (Home)

E-mail: __________________________________________ _____________________

____________________________

(Office)

(Mobile Phone)

2.

PRESENT OCCUPATION Position held/Department: ______________________________________ Starting date: _____________ Name and address of organization: ________________________________________________________ ____________________________________________________________________________________

3.

ACADEMIC & PROFESSIONAL QUALIFICATIONS ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

4.

I wish to enrol in the following session:

  5.

Whole session (16-19 Nov 2013) HK$4,000 Weekend session (16-17 Nov 2013) HK$2,500

COURSE FEE Bank Name: _______________________ Cheque No.: ______________ Amount: HK$ _____________ Candidate’s Signature ________________________________________ Date______________________