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Make sure that your PCR membership data is updated
Please complete this form and fax to 3738462.
PHILIPPINE COLLEGE OF RADIOLOGY MEMBERSHIP DATA BANK
Please fill this up completely because this will be used for the PCR ID system
NAME______________________________________________________________
DATE OF BIRTH______________________________________________________
PRC LICENSE NUMBER _________________
PMA NUMBER ________________________ CHAPTER ____________________
STATUS IN PCR
_______ Resident-In-Training
_______ Diplomate
_______ FPCR
RADIOLOGY RESIDENCY & FELLOWSHIP TRAINING (HOSPITAL, INCLUSIVE DATES, TRAINING OFFICER)
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DATE INDUCTED TO THE PCR_________________________________
DATE INDUCTED AS FELLOW OF THE PCR________________________
MEMBERSHIP IN PCR SUBSPECIALTIES & YEAR INDUCTED
_______ CT-MRI
_______ USP
_______ PSVIR
_______ PROS
_______ Diagnostic Breast Imaging Society
CHAPTER MEMBERSHIP
_______ NCR
_______ Central & Northern Luzon
_______ Southern Luzon
_______ Visayas & Northern Mindanao Chapter
_______ Southern Mindanao
MAILING ADDRESS & PHONE
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PERMANENT ADDRESS & PHONE
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EMAIL ADDRESS
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MOBILE NUMBER __________________________
CLINIC ADDRESS (LOCATION/ AREA OF PRACTICE), SCHEDULE & CONTACT NUMBER
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TITLE OF PAPERS / AUTHORSHIP / REMARKS
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POSITION(S) IN PCR & INCLUSIVE DATES
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WITH SPECIAL INTEREST IN
_______ Neuroradiology / ENT _______ Women’s Imaging
_______ MSK _______ Pediatric Imaging
_______ Cardiovascular Imaging _______ GIT
_______ Pulmonary Imaging _______ GUT
WITH TRAINING IN (SUBJECT, PLACE, INCLUSIVE DATES)
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OTHER ORGANIZATIONS (please indicate inclusive years and position)
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HOBBIES & TALENTS
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(SIGNATURE OVER PRINTED NAME)
DATE THIS FORM WAS FILLED UP _____________
Please use back page if necessary. Please write legibly so as to avoid mistakes in encoding. Kindly return this to the secretariat / registration committee
THANKS FOR YOUR TIME
Prepared by: Ma Elsie M. Dimaano,MD
