長庚紀念醫院代訓醫務人員申請表

Chang Gung Memorial Hospital Training Application Form

 西 ‧牙醫師（ Medical Doctor） Application Date：2009/ /
Name (中文) 身份證字號 兩吋相片
(ID No.)
姓名
(英文) (中文姓名) (Photograph)
/ 護照號碼
(Passport No.)
(Given Names / Surname) 出生年月日 19 / /
(Birth Date)
籍 貫 省 市 性 別  男 (Male)
(Sex)
(國 籍) 市 縣  女 (Female)
(Nationality) 婚 姻  已婚 (Married)
(Marriage)
 未 婚 (Unmarried)
 其他 (Others)
執業地點 執業國家  本 國 (Taiwan)
(Working organization) (Working country)
 其他 (Others)：____________________
通 訊 處住家（Home Address）： 電話
(Mailing Address)
公司（Office Address）： (Phone)
應檢附文件 (Documentations required)：

1. 報名表 (Registration & Reservation form)

2. 代訓醫務人員申請表 (Training Application form)
3. 個人履歷證件 (Curriculum Vitae)
4. 畢業證書影本一份 (Copy of medical school or university graduate certificate)
5. 醫事人員證書、執業執照影本各一份 (Copy of medical doctor license)
6. 經歷證明影本一份 (Copy of medical personnel certificate, employment at least for 1 year)
7. 服務機關正式公文或推薦信
(Recommendation letter or reference from your working organization)
8. 護照影本一份 (Copy of Passport and visa)
9. 照片 2 張 (Photograph, two copies)
10. 國內執業醫師：切結書
學 畢業學校 科系 畢業年度
(Educated school) (College department) (Educated years)
經 服務機關 職務 服 務 起 訖
(Academic Appointment & Employment Record) (Title) (Employment duration)
歷
/ / ~ / /
/ / ~ / /
/ / ~ / /
代訓科別 針灸科 代訓方式 課室教授及臨床見習觀察員
(Training department) (Department of Acupuncture) (Training course) (acupuncture fundamentals and observing courses)
代訓期間 自 98 年 4 月 25 日至 98 年 5 月 3 日 計 9 日（48 小時）
(Training Period) (April 25th , 2009 – May 3rd, 2009. 9 days (48 hours))

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申 1.“Workshop on Clinical Training Program of Acupuncture Skills” includes Acupuncture fundamentals and
th rd
請 observing courses from April 25 , 2009 to May 3 , 2009 (9 days (48 hours)).

說 2. Registration fees: Free! (sponsored by CCMP97-RD-209, Committee on Chinese Medicine and

明 Pharmacy, Department of Health, Taiwan). Registration includes: Admission to the workshop, Certificate
of attendance, Workshop teaching Materials and Workshop Manual.

簽章 (Signature)：

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