NUSAGE-PAREXEL Post-Graduate Certificate in Clinical Trial Management Name of Applicant (as it appears in NRIC/Passport and underline Surname/Family name) Source of Advertisement (How did you come to know about NUSAGE and/or our graduate programme? Please include the reasons for choosing NUS and to which other university universities have you applied?) Financial Assistance (Please tick in the relevant box) Self-Finance (Bank Draft or Cheques to be made payable to "National University of Singapore", with your name, IC no. and module title indicated at the back of the cheque.) Sponsorship (Please Specify Company) A letter of confirmation from a sponsor to be enclosed. Submission of Application Form (by mail or fax) National University of Singapore, Department of Pharmacy, Faculty of Science, S4 Level 2 Room 18, 18 Science Drive 4, Singapore 117543 Fax no.: 67791554 IMPORTANT!!! Other documents required 1. Passport size photograph attached on the application form, and also to email with subject title, NUSAGE-PAREXEL GCP Application [your full name], a soft copy photograph of 340 x 453 pixel (colored photograph) in JPG format to phacyj@nus.edu.sg 2. Copies of academic certificates please present photocopies of your originals in the application first. (Upon successful admission into the programme, Certified True Copies of scrolls/transcripts will have to be submitted in place of originals) NUS graduates will have to approach the Student Service Centre to certify their documents. See http://www.nus.edu.sg/osa/ssc/. For foreign graduates, the official transcript must be enclosed in a SEALED envelope with its flap bearing the security seal of the university and the signature of the Registrar or his representative. You are responsible for requesting your transcript from the university concerned. If you have attended more than one university, you should make photocopies of the Transcript Request Form as required. (See last page) 3. A copy of IC (back & front) (original IC will be required for certification upon confirmation of registration) Acknowledgement of Application An email will be sent to the applicant upon successful outcome of application. Please ensure that the email address stated in the application form is correct. All payments must be fully received by NUS before commencement of class.
[1] PERSONAL PARTICULARS Title : Mr. / Miss / Mrs / Madam Full Name : (as in NRIC/ Passport or other Official Document) Photograph of Applicant Family Name / Surname : Given Name : Sex : Female Male Date of Birth (DD/MM/YYYY) : Place of Birth : NRIC/Passport No. : Ethnic Group (Please tick in the relevant box) Chinese Malay Caucasian Indian Eurasian Others (Specify ) Citizenship (Please tick in the relevant box) Singaporean Malaysian India Singapore PR P R China Others (Specify ) For Singaporean and Malaysian only (Please tick in the relevant box) Singapore Pink Malaysian Blue Singapore Blue Malaysian Pink NS - Singaporean Only (Please tick in the relevant box) Completed (ORD : ) Disrupted Not Applicable Serving (ORD : ) Exempted Marital Status (Please tick in the relevant box) Single Separated Widowed Married Divorced No. of children
Contact Information Home Address: Mailing Address: (If different from Home Address) Email Address: Tel No. (Home): Tel No. (Mobile): Tel No. (Office): Fax No.: [2] PARTICULARS OF NEXT-OF-KIN Name (Mr./Miss/Mrs/Mdm): Home Address: Relationship: Tel No. (Office): Tel No. (Home): Tel No. (Mobile): [3] ACADEMIC QUALIFICATIONS (Attach original/certified true copies of certificates, degrees and transcripts. Graduates of foreign universities, please use the attached transcript request form for official transcripts to be sent direct from your universities) From To Institutions Attended Degree Class / Rank
[4] MEMBERSHIP OF PROFESSIONAL ORGANISATIONS From To Organisation Membership Status [5] SCHOLARSHIPS, PRIZES OR OTHER AWARDS RECEIVED From To Details Organisation [6] WORK EXPERIENCE, INCLUDE PRESENT OCCUPATION From (Mth/Yr) To (Mth/Yr) Name & Location of Organisation (Indicate Department) Title & Job Description [7] MAJOR EXTRA-CURRICULAR ACTIVITIES / COMMUNITY ACTIVITIES From To Activities Office position held / Honours Elected / Appointed [8] LANGUAGES (Please tick in the relevant box) Spoken Written Languages Fair Good Excellent Fair Good Excellent
[9] OTHER INFORMATION (Please tick in the relevant box) (a) (b) Have you previously applied for admission or been admitted to any postgraduate programme(s) in NUS? No / Yes (delete where appropriate). If Yes, Programme(s) applied for : Year of application : Outcome of application : Successful / Rejected (please delete accordingly) If you have applied to another department in the Faculty of Science, please state the second department which you have applied to: Programme (s) applying for: [10] PERSONAL STATEMENTS / LETTERS OF MOTIVATION (To applicant: Discuss your academic and career objectives. If you are sponsored by your company, please describe the deliverables and objectives of the company sponsorship. Please use an additional sheet if necessary.) DECLARATION 1. Have you ever been convicted of any offence by a court of law in any country or are there Yes / No any court proceedings pending against you anywhere in respect of any offence? 2. Are you currently, or have you ever been, charged with or subject to disciplinary action for Yes / No any type of misconduct, scholastic or otherwise, at any educational institution? 3. Are you currently, or have you ever been, under investigation or subject to enquiry in respect Yes / No of any misconduct, scholastic or otherwise, at any educational institution? If your answer to any or all of the above questions is yes, please provide a full statement of relevant information on a separate sheet of paper (and attach the relevant documents). I hereby declare that all information provided by me in connection with this application is true, accurate and complete. I understand that any inaccurate, incomplete or false information given or any omission of information required shall render this application invalid and NUS may at its discretion withdraw any offer of acceptance made to me on the basis of such information or, if already admitted, I may be liable to disciplinary action, which may result in my expulsion from NUS. I hereby authorise NUS to obtain and verify any part of the information given by me from or with any source, as it deems appropriate. Signature Date
Transcript Request Form To: The Applicant Please complete this section of the form and send it to the Registrar (or relevant person-in-charge) of the University from which you are requesting your transcript. Applicant s Name: Date of Birth: Applicant s Address: University: Date of Enrolment: From To Field of Study: Degree: Date of Conferment: Programme applied for: To: The Registrar / Person-In-Charge 1. The person whose name appears above is applying for our post-graduate certificate course. 2. The application cannot be considered without an official academic records submitted by your University. This transcript must bear the stamp of your University and the name and signature of the Registrar or authorised person. 3. Subject to the rules governing your University, the transcript should include: (a) Date of enrolment; (b) A list of all subjects taken (with dates), and the grades obtained in each subject; (c) Title of degree awarded and date of conferment; (d) Rank in class; (e) Interpretation or explanation of the grades, marks or scores. 4. If the transcript is in a language other than English, please provide an official translation. 5. PLEASE DO NOT RETURN TO APPLICANT. Please send the official transcript together with this form to the address below. NUSAGE Department of Pharmacy National University of Singapore 18 Science Drive 4 S4 Level 2 Room 18 Singapore 117543