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

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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Ar Jay
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69 views2 pages

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

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.

Uploaded by

Ar Jay
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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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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