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Full Name(Surname first) 英文姓名(姓氏先行)*:

Name in Chinese 中文姓名:

Sex 性別*: M 男 F 女

HK ID Card/Passport No
香港身份證/護照號碼*:

Date of Birth 出生日期:

Nationality 國籍:

Please tick if you are a non-local applicant
若非本地申請人，請勾選方格

Correspondence Address 通訊地址(英文):

Email*:

Tel. No.(Office) 辦公室電話:

Fax No. 傳真號碼:

WhatsApp 即時通訊程式:

a. Academic qualifications 學歷

Awarding Institution 頒發機構	Title of Award 學銜	Year of Award 頒發年份

b. Professional qualifications 專業資格

Awarding Institution 頒發機構	Title of Award 學銜	Year of Award 頒發年份

c. Working experience 工作經驗

From 由	To 至	Full Time/ Part Time 全職/兼職	Working Hospital/ Institute/Organization 任職機構名稱	Working Department/ Unit/Specialty 任職部門/單位/專科	Rank 職位
		Fulltime Parttime
		Fulltime Parttime

d. Other information relevant to this application 其他相關資料

Application Fee: $500.00

4. Apply for the Professional Title for registered nurses and registered midwives 申請專業資格

To enhance the professional development of continuing education for nurses and midwives; the College encourages and welcomes a registered nurse or registered midwife, whom admitted to practice the professions of nursing or midwifery administrative or management practice, to apply the Associate Fellow of HKCNHCM.
為提昇護士及助產士的專業發展及持續進修，香港護理及衞生管理學院設立副院士制度，積極鼓勵並歡迎有意實踐護理於行政及管理專業化的註冊護士及註冊助產士申請成為本學院之副院士。

I am interested in applying to be the Associate Fellow of the HK College of Nursing and Health Care Management.
本人有興趣申請成為香港護理及衞生管理學院的副院士

5. Declaration 聲明

I authorise HK College of Nursing and Health Care Management to use my personal data for processing my application for admission and for transferring to the student record system when I am offered a place of study. I understand that the information will be used in activities in support of my study at the College.
本人授權香港護理及衞生管理學院及使用本申請表內有關的個人資料作處理申請入學之用。本人明白若獲得學院取錄，本人的資料將會轉為學院的學生紀錄，並用於有關教學事宜之上。

I declare that all particulars given in this form are true and correct to the best of my knowledge and understand that provision of any false and misleading information will lead to disqualification of my application for admission and registration in the College. Any fees paid will not be refunded.
本人謹此聲明，此表格內所填報各事項，均屬真實無訛，如有任何虛報或誤導資料，則本人的申請及註冊資格均會被取消，所有已繳費用概不退還。

I understand that the above course(s) is/are not Continuing Education Fund reimbursable course(s).
本人知悉及明白以上報讀之課程均不能申請持續進修基金。