How to become a member of PHA?

To apply as a member of the Philippine Heart Association, please print and fill up the application form below, and then send to PHA via fax or email. Fax no.: (02) 6877797. E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it..

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PHILIPPINE HEART ASSOCIATION, INC.

PHILIPPINE COLLEGE OF CARDIOLOGY

 
Suite 1108, 11th Flr. East Tower, PSE Centre, Exchange Road
Ortigas Center, Pasig City, Philippines 
 
 

Tel. # (02) 4705525, (02) 4705528 / Fax # (02) 6877797

 

 


Date: ____________________

 

 

 

NOTE: Please TYPE or PRINT legibly all information. Provide extra sheet if necessary. Please fill all blanks.

Where information is not available, place “none” or “not applicable”. Incomplete or illegible forms will be returned.

 

 

 

GENERAL DATE:

 

 

 

 

 

NAME: Last

First

  M.I.

BIRTHDATE:

_________________________________

_____________________

  _____

_______________

 

 

 

ADDRESS:

 

 

Residence:

Principal Office:

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

____________________________________

Phone: ________________________

Phone: ________________________

 

 

Place asterisk (*) before address preferred for correspondence concerning this application.

 

 

HOSPITAL AFFLIATIONS:

ADDRESS:

1. __________________________________

____________________________________

2. __________________________________

____________________________________

3. __________________________________

____________________________________

 

 

MEDICAL EDUCATION:

 

 

Medical School: ______________________________

Date Graduated: ________________

Internship:  _________________________________

Date Graduated: ________________

Residency: _________________________________

Date Graduated: ________________

 

 

PAST PROFESSIONAL POSITIONS: (As trainee; faculty; hospital or government medical appointee. Exclude professional organizations)

Institution

Position

Dates

___________________________

_______________________

_____________________

___________________________

_______________________

________________________

___________________________

_______________________

________________________

___________________________

_______________________

_____________________

 

 

 

If not in practice now (e.g., still in training), or in practice but intending to relocate, state intended place of practice, if locating or relocating before this coming December 15)

 

 

 

City/ Town/ Province: _____________________________________________________________

 

PROFESSIONAL POSITIONS: (As trainee; faculty; hospital or government medical appointee)

Institution:;

Position

_______________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

 

 

SCIENTIFIC CONTRIBUTIONS: (Publications, discoveries, inventions. If publication, use bibliographic style of the Philippine Journal of Cardiology)

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

 

PROFESSIONAL PRACTICE HISTORY:(State type of practice, for examples: Family Medicine, Internal Medicine, Pediatric Cardiology, Adult Cardiology, etc.)

 

Dates:

_________________________________________________

____________________________

_________________________________________________

____________________________

_________________________________________________

____________________________

_________________________________________________

____________________________

 

 

Do you do the following? Please check:

[ ] Electrocardiography

[ ] Echocardiography

[ ] Vectorcardiography

[ ] Cardiac Catheterization

[ ] Cardiac Flouroscopy

[ ] Angiography

[ ] Exercise Stress Testing

[ ] Ambulatory ECG Monitoring

[ ] Other Special Procedures: ______________________________________________________

 

 

PROFESSIONAL ORGANIZATIONS:

Position or Membership Category:

_______________________________________

______________________________________

_______________________________________

______________________________________

_______________________________________

______________________________________

 

AWARDS/HONORS:

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

 

MEMBERSHIP CATEGORY APPLIED FOR: (Please check one.)

[ ] Fellow

[ ] Associate Fellow

[ ] Associate

 

This is a

[ ] first application

 

[ ] application for advancement from (state membership category) ___________________

 

SPONSORS: (Two (2) Fellow of the College):

NAME:

1. ____________________________________________

 

2. ____________________________________________
 

NOTE: Letters of recommendation from two (2) Fellows of the College is required.

 

I hereby certify that the information contained in this application form is true and correct to the best of my knowledge and

that I am conversant with the “INFORMATION FOR CANDIDATES FOR MEMBERSHIP OR ADVANCEMENT “

(Revised, November 24, 1989) issued by the Philippine Heart Association
 

 

Applicant Signature:

 


_________________________________

 

NOTE: Please submit this application to the MEMBERSHIP COMMITTEE, c/o The Secretariat,

Philippine Heart Association, Suite 1108, 11th Flr. East Tower, PSE Centre, Exchange Road,
Ortigas Center, Pasig City, Philippines, or if applying through a Chapter,

submit to the appropriate committee of the CHAPTER, with copies of supporting documents of training, board certification(s),

publication(s), etc. Sponsorship letters shall be sent under separate cover by sponsoring Fellows.

 

Applicant: Please do not write below this line.

__________________________________________________________________________________

 

FOR APPLICATIONS COURSED THROUGH A CHAPTER:

 

Chapter Name: _____________________________________________________________________

Chapter Remarks and Recommendations: ________________________________________________

_________________________________________________________________________________

 
Chapter President:


 ____________________________________________

 

 

Signature over Printed Name

 

Application form, together with all supporting documents, shall be forwarded to the PHA Membership Committee not later

than December 15 following the filing of this application.

___________________________________________________________________________________

FOR PHA MEMBERSHIP COMMITTEE USE ONLY:

Committee Action:

_____________________________________________________________________________________

_______________________________________________________________________________________

 

Cates F. Moradoo

10/ 13/ 2005

 

 

 

 

 

 

 

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