Application Form Application to join the NUHS Clinician Scientist Academy Full Name Academic credentials Affiliation Research interest and/or projects: Year of first medical degree Other Personal Details MCR number Email Address Mobile Number (optional, to join WhatsAPP Chat Group) Official Affiliation NUHS Department Clinical Rank Select... Sr Con Con Assoc Con SR R NUS Appointment Yes No NUS Junior Faculty award Yes No MOHH Yes No Postgrad Degrees MCI Year Started Year Awarded PhD Year Started Year Awarded ASTAR scholar, if applicable Year Started Year Ended Research Clinical Research Yes No Clinical Research Mentor(s), if applicable Basic Research Yes No Basic Research Mentor(s), if applicable Research Training Award NCSP award Year Started Year Awarded RTF award Year Started Year Awarded Other awards? Grant Award (if applicable) NMRC award Select... STAR CSA SI CSA INV HPHSR CIDA CIA TA Others STAR - Year Awarded CSA SI - Year Awarded CSA INV - Year Awarded TA - Year Awarded Other Awards, please specify name and year of award: Name of award: Year of award: By submitting this form, you consent to the NUHS Clinician Scientist Academy storing, using and /or disclosing the information you provided to third parties for the purposes of administering and managing your membership and participation in the academy’s programs and related purposes. Submit
