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
Tel. # (02) 4705525, (02) 4705528 / Fax # (02) 6877797 |
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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. |
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GENERAL DATE: |
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NAME: Last |
First |
M.I. |
BIRTHDATE: |
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ADDRESS: |
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Residence: |
Principal Office: |
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Phone: ________________________ |
Phone: ________________________ |
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Place asterisk (*) before address preferred for correspondence concerning this application. |
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HOSPITAL AFFLIATIONS: |
ADDRESS: |
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1. __________________________________ |
____________________________________ |
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2. __________________________________ |
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3. __________________________________ |
____________________________________ |
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MEDICAL EDUCATION: |
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Medical School: ______________________________ |
Date Graduated: ________________ |
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Internship: _________________________________ |
Date Graduated: ________________ |
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Residency: _________________________________ |
Date Graduated: ________________ |
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PAST PROFESSIONAL POSITIONS: (As trainee; faculty; hospital or government medical appointee. Exclude professional organizations) |
Institution |
Position |
Dates |
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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) |
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City/ Town/ Province: _____________________________________________________________ |
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PROFESSIONAL POSITIONS: (As trainee; faculty; hospital or government medical appointee) |
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Institution:; |
Position |
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SCIENTIFIC CONTRIBUTIONS: (Publications, discoveries, inventions. If publication, use bibliographic style of the Philippine Journal of Cardiology) |
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PROFESSIONAL PRACTICE HISTORY:(State type of practice, for examples: Family Medicine, Internal Medicine, Pediatric Cardiology, Adult Cardiology, etc.) |
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Dates: |
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Do you do the following? Please check: |
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[ ] Electrocardiography |
[ ] Echocardiography |
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[ ] Vectorcardiography |
[ ] Cardiac Catheterization |
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[ ] Cardiac Flouroscopy |
[ ] Angiography |
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[ ] Exercise Stress Testing |
[ ] Ambulatory ECG Monitoring |
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[ ] Other Special Procedures: ______________________________________________________ |
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PROFESSIONAL ORGANIZATIONS: |
Position or Membership Category: |
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AWARDS/HONORS: |
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MEMBERSHIP CATEGORY APPLIED FOR: (Please check one.) |
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[ ] Fellow |
[ ] Associate Fellow |
[ ] Associate |
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This is a |
[ ] first application |
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[ ] application for advancement from (state membership category) ___________________ |
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SPONSORS: (Two (2) Fellow of the College): |
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NAME: |
1. ____________________________________________ |
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2. ____________________________________________ |
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NOTE: Letters of recommendation from two (2) Fellows of the College is required. |
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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 |
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Applicant Signature: |
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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, 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. |
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Applicant: Please do not write below this line. __________________________________________________________________________________ |
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FOR APPLICATIONS COURSED THROUGH A CHAPTER:
Chapter Name: _____________________________________________________________________ Chapter Remarks and Recommendations: ________________________________________________ |
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Signature over Printed Name |
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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. |
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___________________________________________________________________________________ FOR PHA MEMBERSHIP COMMITTEE USE ONLY: Committee Action: _____________________________________________________________________________________ |
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Cates F. Moradoo 10/ 13/ 2005
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