Duke‐NUS Graduate Medical School Fellowship in Team‐Based Learning Registration Form Please submit the completed registration form and your most recent CV:
Medical Education, Research and Evaluation (MERE), Duke‐NUS Graduate Medical School, 8 College Road, Singapore 169857. faculty.development@duke‐nus.edu.sg
Postal Address: Email: Fax: Attention:
(+65) 6227 2698 Ms. Lata Jaybalen
Workshop Dates
Workshop Series 1
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23 – 27 April 2012
Workshop Series 2
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3 – 7 December 2012
Workshop Series 3
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2013 dates to be advised
Personal Particulars (Complete all sections) *Salutation
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Name as in Passport (Please underline Family Name)
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MCR No (if applicable)
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Designation
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Department
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Organization
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Contact Number : (please include country code and area code where appropriate)
Prof
A/P
Dr
Mr
Mrs
Ms
Mdm
_____________________________________ (Phone) _____________________________________ (Mobile) _____________________________________ (Fax)
Email address
* Select only 1
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