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    Philippine Hospital Infection Control Society (Phics), Inc.: Application For Membership

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    Ar Jay
    This document is an application form for membership in the Philippine Hospital Infection Control Society. It requests personal information from the applicant such as name, age, contact details, academic and professional background including degrees, residency training, postgraduate courses, present positions, and membership in other organizations. The form has spaces for endorsements from the applicant's Infection Control Officer and hospital. It also has sections for the committee on membership and board to note their approval or disapproval of the application.

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    Attribution Non-Commercial (BY-NC)
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    Philippine Hospital Infection Control Society (Phics), Inc.: Application For Membership

    Uploaded by

    Ar Jay
    13 views2 pages
    This document is an application form for membership in the Philippine Hospital Infection Control Society. It requests personal information from the applicant such as name, age, contact details, academic and professional background including degrees, residency training, postgraduate courses, present positions, and membership in other organizations. The form has spaces for endorsements from the applicant's Infection Control Officer and hospital. It also has sections for the committee on membership and board to note their approval or disapproval of the application.

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    phicsna

    Original Title

    ohicna

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    This document is an application form for membership in the Philippine Hospital Infection Control Society. It requests personal information from the applicant such as name, age, contact details, academic and professional background including degrees, residency training, postgraduate courses, present positions, and membership in other organizations. The form has spaces for endorsements from the applicant's Infection Control Officer and hospital. It also has sections for the committee on membership and board to note their approval or disapproval of the application.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    13 views2 pages

    Philippine Hospital Infection Control Society (Phics), Inc.: Application For Membership

    Uploaded by

    Ar Jay
    This document is an application form for membership in the Philippine Hospital Infection Control Society. It requests personal information from the applicant such as name, age, contact details, academic and professional background including degrees, residency training, postgraduate courses, present positions, and membership in other organizations. The form has spaces for endorsements from the applicant's Infection Control Officer and hospital. It also has sections for the committee on membership and board to note their approval or disapproval of the application.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 2

    PHILIPPINE HOSPITAL INFECTION CONTROL

    SOCIETY (PHICS), INC.


    APPLICATION FOR MEMBERSHIP
    Last Name: |__|__|__|__|__|__|__|__|__|__|__|__| First Name: |__|__|__|__|__|__|__|__|__|__|__| Middle Initial: |__|
    Age: |__| Sex: |__| Civil Status: |__| Mobile Phone # ___________________ E-mail add. _____________________
    Residence: __________________________________________________________ Telephone No: ___________
    ____________________________________________________________________
    Hospital Affiliation:_____________________________________________________ Telephone No. ___________
    ____________________________________________________________________ Fax No. ________________
    ____________________________________________________________________ _______________________
    LIC. # _________________ PRC # __________________________
    PMA # ___________________________

    ACADEMIC DEGREES
    ________________________________
    ________________________________
    ________________________________

    UNIVERSITY/INSTITUTION
    ________________________________________
    ________________________________________
    ________________________________________

    DATE
    _______________
    _______________
    _______________

    RESIDENCY TRAINING (for MDs only)


    ________________________________
    ________________________________
    ________________________________

    ________________________________________
    ________________________________________
    ________________________________________

    _______________
    _______________
    _______________

    POSTGRADUATE COURSE:
    ________________________________
    ________________________________
    ________________________________

    ________________________________________
    ________________________________________
    ________________________________________

    _______________
    _______________
    _______________

    PRESENT POSITION(s):
    ________________________________
    ________________________________
    ________________________________

    ________________________________________
    ________________________________________
    ________________________________________

    _______________
    _______________
    _______________

    MEMBERSHIP IN LEARNED SOCIETIES AND PROFESSIONAL ORGANIZATIONS:


    (Please indicate if present or past officer)
    ________________________________ ________________________________________
    ________________________________ ________________________________________
    ________________________________ ________________________________________

    _______________
    _______________
    _______________

    _________________________________________________
    Signature over Printed Name of Applicant

    Page 1 of 2 pages

    ___________________________
    Date

    ENDORSEMENTS:

    Endorsed by:
    _________________________________________
    Infection Control Officer

    _______________________
    Date

    _________________________________________
    Hospital/Institution

    DO NOT FILL BELOW THIS LINE

    Approved for membership


    Disapprove. For further evaluation.
    Remarks:
    __________________________________
    Chair, Committee on Membership
    ___________________
    Date

    ACTION OF THE BOARD:

    Approved

    Date: ______________________

    Disapprove

    Date: ______________________

    Remarks:
    ____________________________________________
    PHICS President
    ____________________________
    Date
    Page 2 of 2 pages

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