REGISTRATION FORM

1ST / 2nd / 3rd MMED (PAEDS) PREPARATORY COURSE 2015

REGION: Klang Valley / East Coast / North / South / Sabah / Sarawak
DATE : ___________________________
VENUE : __________________________
Personal Information
Name
Age
Gender
IC / Passport No.
Telephone number
Home address

Email add (please state clearly)

Undergraduate Training
Year graduated
University graduated from

Working Experience
Designation (current)
Current working place
Years of paediatric experience
(excluding

HO

training

duration)
MRCPCH Part 1A / 1B / 2A

Yes ( ), Please state:

No ( )

REGISTRATION FEES: RM 200

Please return the completed form to regional coordinator. Your seat only confirm after the
coordinator receive the full payment of the registration fees.
Please pay the registration fees by cheque or cash to the respective coordinator at least 2
weeks before date of each course. LPO not accepted
Cheque to be made payable to Bendahari Universiti Malaya.