Mailing Address. Contact Number. Section C. BACKGROUND OF MEDICAL EDUCATION. Country of Medical School. Name of Medical
NATIONAL UNIVERSITY HOSPITAL Application Form for Clinical Electives
Section A. PARTICULARS OF APPLICANT
MR / MISS / MRS Title* First Name Last Name (Surname) Male / Female Gender* Day Date of Birth
Month
Year
Nationality NRIC / Passport Number Email Address Mailing Address
Contact Number
Section B. PARTICULARS OF APPLICANT'S NEXT-OF-KIN
DR / MR / MISS / MRS Title* First Name Last Name (Surname) Male / Female Gender* Relationship Mailing Address
Contact Number
Section C. BACKGROUND OF MEDICAL EDUCATION Country of Medical School Name of Medical School
Is your school on a Bilateral Exchange Agreement (BEA) with NUS?*
YES / NO
If your school is on a BEA with NUS, please state your reasons for applying for NUH Clinical Electives:
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NATIONAL UNIVERSITY HOSPITAL Application Form for Clinical Electives
Name of Home University's Elective Coordinator
Elective Coordinator's Email Address
Elective Coordinator's Contact Number Mailing Address
Are you in your clinical years?*
YES / NO
2/ 3/ 4/ 5/ 6/ 7 Current Year of Study* Year of Elective (year of study upon commencement of elective )*
3/ 4/ 5/ 6/ 7
Expected Month/ Year of Graduation
Month
Year
Have you done any electives at NUH previously?*
YES / NO
If YES, please provide details of your previous elective: Specialty/ Hospital Division Duration of Posting Commencement of Posting End of Posting
weeks DD/MMM/YYYY DD/MMM/YYYY
Section D. REASON FOR APPLICATION Please highlight your keen interest in pursuing a clinical elective with National University Hospital and why the Hospital should consider your application. Please highlight why the Department should consider your application.
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NATIONAL UNIVERSITY HOSPITAL Application Form for Clinical Electives
Section E. POSTING REQUEST This section allows you to indicate your preference of posting request(s). Please note the following key points when making your choice(s): • You may apply to do an elective at a maximum of 2 departments/ divisions. Please write to us if you would wish to do so. • You are given 2 posting options. We advise that you use up both options as not all postings may have vacancies. • Your choices will be processed in order of the preference stated in the application form. • The minimum and maximum total posting duration are 2 weeks to 12 weeks respectively. • Your posting start date must begin on a Monday. • Your application must be made at least 3 months before the commencement of your posting.
Posting Choice Posting Option 1 Specialty/ Hospital Division Duration of Posting Posting Period
Start Date: End Date:
weeks DDMMMYYYY DDMMMYYYY
Start Date: End Date:
weeks DDMMMYYYY DDMMMYYYY
Posting Option 2 Specialty/ Hospital Division Duration of Posting Posting Period
*delete whichever is not applicable
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NATIONAL UNIVERSITY HOSPITAL Application Form for Clinical Electives
Section F. Approval [information will be input by Medical Affairs (Education)/ EDO]
Name of Student Medical School Posting period applied Department/ Division Supervisor
