Professional Certificate Programme in Chinese and Integrative Medicine Management (CIMM)- Application Form

Name Name * First Last
Chinese Name
Sex

Sex Male Female
HKID Card No.
Passport No. (If you do not have a HKID Card)
Passport Expiry Date Passport Expiry Date / DD / MM YYYY
Nationality *
Place of Birth *
Date of Birth Date of Birth * / DD / MM YYYY
Mobile Number *
Email *
Home Address Home Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Academic Qualifications (Institution and Location) *
Professional Qualifications (Awarding Body and Year Obtained) *
Working Experiences (Institution, Position and Years in the Position) *
Your Expectation of the Programme *
I will send the following supporting documents in soft copies to healthadmin@cuhk.edu.hk with Email Subject: CIMM 2022-23 Application - (Your Full Name). *

I will send the following supporting documents in soft copies to healthadmin@cuhk.edu.hk with Email Subject: CIMM 2022-23 Application - (Your Full Name). Photocopy of identity card Copies of qualification certificates A recommendation letter A personal statement
Declaration:
1. I hereby declare that the information provided in this form and relevant documents attached are correct to the best of my knowledge.
2. I understand that the Application fee (HK$300), once paid, is not refundable.
3. I understand that the Programme fee, once paid, is not refundable.
4. The Application fee paid by crossed cheque made payable to "The Chinese University of Hong Kong" will be sent to Room 202, 2/F, School of Public Health Building, Prince of Wales Hospital, Shatin, N.T. (CIMM 2022-23)
5. The Programme fee paid by crossed cheque made payable to "The Chinese University of Hong Kong" will be sent to Room 202, 2/F, School of Public Health Building, Prince of Wales Hospital, Shatin, N.T. (CIMM 2022-23)
I agree to the above terms as listed in the declaration. *

I agree to the above terms as listed in the declaration. Yes No
Signature *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
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