Dermatological Society of Singapore

Membership Application Form

(Please fill in all the blanks)

Title:
Dr    Mr     Ms

Surname:                        Given Names:
  

Email Address:

Member Type:
Ordinary    Associate     Overseas

Application Date: (ie. DDMMYY)    

Birth Date: (ie. DDMMYY)

Sex:
Male    Female

Nationality:

Office Address:

Telephone:      Fax:

Home Address:

Telephone:      Handphone:

Preferred Postal Address:
Home    Office

Qualification/Year

Medical Society Membership:
(List any office or committee appointments you hold or have held)

Dermatological Interest:
The Dermatological Society of Singapore constitution requires that the
applicant practices or has an interest in dermatology. Please provide
evidence of your interest in dermatology (eg. training, attendance at
dermatology talks or courses, etc). Please enclose relevant certification
of attendances.

Member Endorsement:
List names of 2 members of the DSS who will endorse your application.
Please forward their letters of endorsement together with your form to
the Secretary.

Endorser 1 Name:

Address:

Endorser 2 Name:

Address:

I certify that the above information is correct as recorded.

NB: The following supporting documents are to be included with your application.

a)     Letters of endorsement

b)    Curriculum vitae

c)    Certified copies of medical degree and medical licenses supporting evidence 

       to attest to the practice of dermatology or interest in dermatology 

       (eg. dermatology meetings, seminars and courses attended.)

The above documents (including this application form) can be sent in printed form
to the following address, or alternatively, be submitted electronically, or
combination of both methods.

The Honorary Secretary
The Dermatological Society of Singapore
Bukit Timah Post Office
P O Box 310
Singapore 915811

Telephone : 65-9129 4583

Email : info@dermatology.org.sg