Sign up! 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) _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ 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 _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ PERMANENT ADDRESS & PHONE _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ EMAIL ADDRESS _____________________________________________________________ MOBILE NUMBER __________________________ CLINIC ADDRESS (LOCATION/ AREA OF PRACTICE), SCHEDULE & CONTACT NUMBER _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ TITLE OF PAPERS / AUTHORSHIP / REMARKS _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ POSITION(S) IN PCR & INCLUSIVE DATES _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ 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) _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ OTHER ORGANIZATIONS (please indicate inclusive years and position) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ HOBBIES & TALENTS ____________________________ _________________________________ ____________________________ _________________________________ ____________________________ _________________________________ ____________________________ _________________________________ ____________________________ _________________________________ ____________________________ _________________________________ ____________________________ (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 |
