Name:
 
Membership Number :     ______
 
1. Sponsored through HKODA with last  
 36 months  ○
 24 months  ○
 12 months  ○
 Never      ○
 
2. Active contribution in the association. If yes, please specify 
 
3. Specialty professional qualification ____________________________________

4. Experience relevant to criteria. If yes, please specify
 
5. Academic presentation at the conference. If yes, please specify