Joint Shantou International Eye Center (JSIEC) Shantou University & the Chinese University of Hong Kong 《美国白内障与屈光手术协会ASCRS·亮睛工程张萬洲白内障手术培训中心(汕头)》 培训项目申请表 《ASCRS Foundation·Project Vision Chang Cataract Surgery Training Center(Shantou)》 Training program application form 姓名(Applicant’s Name) 单位名称(Current institute) 单位等级(Classification of institute) 联系电话(Telephone) 填表日期(Date): 年(Year) 月(Month) 日(Day) 进修申请表应填写清楚,内容真实可信 Please make sure that all information is accurate 姓名 Name
性别 Gender
出生日期DOB
籍贯place of ancestry
民族Nationality
政治面貌Political State
学历Academic degree
健康状况Health status
所属专业Subspecialty
技术职称Title
行政职务Position
执业医师资格 Medical License 医师资格证书编码(Certification #): 医师执业证书编码(Registration #): 学历及工作经历 Brief CV 现有技术水平及 显微手术能力 Current clinical and surgical ability
进修专业、内容Proposed subspecialty
进修期限Proposed duration 月(Months) 预期达到的进修目标Purpose of fellowshi
