INSTITUT JANTUNG NEGARA www ijn com my S N IT No 145 Jalan Tun Razak 50400 Kuala Lumpur Tel 03

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INSTITUT JANTUNG NEGARA www ijn com my S N IT No 145 Jalan Tun Razak 50400 Kuala Lumpur Tel 03 Powered By Docstoc
					INSTITUT JANTUNG NEGARA www.ijn.com.my                                                                                                S/N-IT :
No. 145, Jalan Tun Razak, 50400 Kuala Lumpur. Tel : (03) 2617 8496/ 2617 8200 Fax : (03) 2698 2824                             Rqst letter dd :
* Please send your completed application form and documents to : The Deputy Medical Director                                    MReply by :

                                              APPLICATION FOR CLINICAL ELECTIVE POSTING
                                                & SUB-SPECIALTY ROTATION PROGRAMME
                                               Undergraduate           Master Programme Student (currently employed / unemployed)
                                         Name of Hospital under current employment

Training in Dept.                             Cardiothoracic Surgery            Cardiology           Paediatric Cardiology        Anaesthesiology &
(May specify more than one)                                                                                                         Intensive Care
                                               Clinical Support Dept. (pls specify)

Name of Applicant                :

Date of Birth                    :                                     Age :                         NRIC/Passport No.
                                         dd/mm/yy

Nationality                      :                                     Tel :                         Fax :               E-mail :

Mailing Address                  :

PROPOSED SELECTIVE/ELECTIVE POSTINGS/SUB-SPECIALTY
     OVERALL period of selective/elective posting/sub-specialty at various department/s (please indicate day, month and year)

          Posting in Department                                                                      From                 To                  Duration
  1.
  2.
              T O T A L                  D U R A T I           O N

SUPPORTING DOCUMENTS (please attach)

  No.                                                Documents
   1          Letter confirming student status (original letter on university stationery)
   2          Letter of Recommendation from the Dean of the Medical School
   3          Letter of Recommendation from the Director of the institution/organisation under current employment

REQUESTED BY                :                                                         SUPPORTED BY               :


Name & Signature            (applicant)                                               Name & Signature (Dean of University/Superior to applicant)


Designation                                                                           Designation



University/Organisation's Name & Official Stamp                                       University/Organisation's Name & Official Stamp

Tel. :                                             Date :                             Tel. :                                         Date :

(The portion below is for IJN's office use only)
RECOMMENDATION :                                                                      ASSIGNMENT OF STUDENT/TRAINEE TO :
                                                                                        Accept
                                                                                          Reject
CLINICAL CHIEF / HOD                                  Date                                                   NAME of CONSULTANT / SUPERVISOR

                                                                                          Accept
                                                                                          Reject
CLINICAL CHIEF / HOD                                  Date                                                   NAME of CONSULTANT / SUPERVISOR
INSTITUT JANTUNG NEGARA
No. 145, Jalan Tun Razak, 50400 Kuala Lumpur. Tel : (03) 2617 8496/ 2617 8200 Fax : (03) 2698 2824
Please send your completed
application form and documents to :
       The Medical Director                                                                                                 :

                                     APPLICATION FOR POSTING OF MEDICAL STUDENT
                                         SELECTIVE              ELECTIVE
Training in Dept.                          Cardiothoracic            Cardiology          Paediatric Cardiology    Anaesthesiology
(May specify more than one)
                                              Others (pls specify)

Name of Applicant                :       Elanggovan s/o Nagandran




… continue from Page 1 - FOR RECOMMENDATION AND APPROVAL




(The portion below is for IJN's office use only)
RECOMMENDATION :                                                                     ASSIGNMENT OF STUDENT/TRAINEE TO :
                                                                                       Accept
                                                                                         Reject
CHIEF of CLINICAL DEPARTMENT                        Date                                             NAME of CONSULTANT

                                                                                         Accept
                                                                                         Reject
CHIEF of CLINICAL DEPARTMENT                        Date                                             NAME of CONSULTANT
       INSTITUT JANTUNG NEGARA                                                                                                                    EP-A2
      No. 145, Jalan Tun Razak, 50400 Kuala Lumpur. Tel : (03) 2617 8496/ 2617 8200 Fax : (03) 2698 2824
      Please send your completed
      application form and documents to :
                The Medical Director                                                                                              Serial No. :    EP/
                                                              APPLICATION FOR ELECTIVE POSTING

       Training in Dept.                                    Cardiothoracic          Cardiology            Paediatric Cardiology       Anaesthesiology
      (May specify more than one)
                                                            Others (pls specify)

       Name of Applicant                     :

       Date of Birth                         :                                     Age :                    NRIC/Passport No.
                                                      dd/mm/yy

       Nationality                           :                                     Tel :                    Fax :                 E-mail :

       Mailing Address                       :


       PROPOSED ELECTIVE POSTINGS
            OVERALL period of elective posting (please indicate day, month and year)
            (Pls state at least 2 alternative postings in addition to your preferred choice (in order of preference)
            Posting in Department                                                           From                   To                               Duration
        1.
        2.
        3.
        4.
                T O T A L              D U R A T I O N

       SUPPORTING DOCUMENTS (please attach)

         No.                                                              Documents

            1          Letter confirming student status (original letter on university stationery)

       REQUESTED BY                    :                                                         SUPPORTED BY             :


       Name & Signature                (applicant)                                               Name & Signature (Dean of University/Superior to applicant)


       Designation                                                                               Designation



       University/Organisation's Name & Official Stamp                                           University/Organisation's Name & Official Stamp

       Tel. :                                                 Date :                             Tel. :                                  Date :

      (The portion below is for IJN's office use only)


       RECOMMENDATION :                               Accept           Reject                    ASSIGNMENT OF STUDENT/TRAINEE TO :


       CHIEF of CLINICAL DEPARTMENT                               Date                           NAME of CONSULTANT

      (Please submit completed form to Medical Division Administrator, tel. no. 03-2617 8496)
       REVIEWED BY                                                                               APPROVED BY


       MANAGER, MEDICAL DIVISION                                       Date                      MEDICAL DIRECTOR                            Date




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Description: Cardiology Office Forms document sample