Reply of Application for Training by pre80674

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									INSTITUT JANTUNG NEGARA                                                                                                               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                                                                                                      MReply by :
application form and documents to :
General Manager
Human Capital Organization Development




                                                   APPLICATION FOR INDUSTRY TRAINING

Training in Dept.                             Bio-medical Engineering            Mechanical & Electrical Engineering
(May specify more than one)
                                              Civil Engineering                  Others (pls specify)



Name of Applicant                :

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

Nationality                      :                                   Tel :                           Fax :               E-mail :

Mailing Address                  :


PROPOSED INDUSTRIAL TRAINING
     OVERALL period of training (please indicate day, month and year)

          Training 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/college/polytechnic/vocational stationery)

    2         Letter of Recommendation from the Dean of the university/college/polytechnic/vocational

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
HEAD of DEPARTMENT                                    Date                                                   NAME of SUPERVISOR

                                                                                         Accept
                                                                                         Reject
HEAD of DEPARTMENT                                    Date                                                   NAME of SUPERVISOR
       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




Med/vickie/FORMS\f9ab9224-015d-48fc-aaf7-3368c78b04f6.xls
Last printed : 7/13/2011 1:36 PM

								
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