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APPLICATION FOR MEDICAL STAFF – ACTIVE & VISITING CONSULTANT

 
Department/Division:
Date: (mm/dd/yyyy)
   
Name:
Date of Birth: (mm/dd/yyyy)
Sex:
Civil Status:
Address:
Telephone Number (Off):
Telephone Number (Res):
 
EDUCATIONAL BACKGROUND
 
High School  
Name of School:
Year:
College  
Name of School:
Year:
Medical School  
Name of School:
Year:
 
Class Standing on Graduation:
Other Degrees (Pls. specify):
 
MEDICAL BOARD EXAMINATION
 
Rating:
Date Passed:
 

POST-GRADUATE TRAINING
 
Internship  
Institution/Address:
Year(s):
Residency  
Institution/Address:
Year:
Fellowship  
Institution/Address:
Year:
Other  
Institution/Address:
Year:
 
Specialty

YEAR PASSED ( If Board Certified )

Membership in Specialty Society
(Please indicate if DIPLOMATE OR FELLOW
Other Hospital Affiliations:
   
Will you be participating in conferences ?

Are you willing to have your patients (with an interesting case) to be presented in the conferences with your permission and try to help us get post-mortem examination :

Other relevant data:
 

To be filled-up by Applicantt for Active Consultant Only

 
How much time can you give for attending conferences?
Days/Time:
Giving Lectures:

Service Rounds:
Other proposed participation in department activities:
If intending to hold clinic, indicate days / time desired:
 

I hereby declare that all above information are true and correct and that I will abide by the rules and regulations of the hospital applicable to my position and in the practice of my profession.

 
 

Please send the following requirements:

 
  1. Curriculum Vitae or Accomplishment of PDS Form; picture 2 x 2 (1 copy only)
  2. Application letter addressed to the Executive Director thru the Department Chair
  3. Photocopy of Diploma from Medical School
  4. Photocopy of PRC Board Certificates / Diploma and PRC License
  5. Photocopy of Internship Certificate; Residency and Fellowship Training Certificates
  6. Photocopy of Certificates as Diplomate & Fellow (Specialty Board)
  7. PHIC Accreditation
  8. Character Reference (3)
  9. Recommendation letter (at least 2)
  10. CME Certificates (in line with your specialty) – at least 3 per year
  11. Signed Consent for Release of Information and Release from Liability
    (will be issued to you by the Medical Services Credentials Committee Personnel)
 

NOTE: PLEASE COMPLY TO ALL THE LISTED REQUIRED DOCUMENTS. ONLY APPLICATIONS WITH COMPLETE REQUIREMENTS SHALL BE PROCESSED.

 
 

 
 
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