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Application Form for US Immersion Program

Surname

Yamin

First Name

Muhammad

Title (Dr, Mr, Mrs, Ms, …)

M.D., PhD, FACC,
FSCAI

Nationality

Indonesia

Gender (M)

Age 52

Residency
(if different from
Nationality)
Current Position

Cardiologist Consultant of Intervention and Electrphysiology,
Cardiology Division of Indonesian University Internal Medicine
Department Medical Faculty. Ciptomangunkusumo National
General Hospital, Jakarta, Indonesia

APHRS Membership ID (Regular member
only):
Preference for before or after HRS 2016?
Preferred institution:
Good Samaritan Hospital, Los Angeles,
California or
Aurora Health, Milwaukee, Wisconsin
Home Address
Blok A3 No.19, Cluster Greencove, BSD City,
Tangerang

Work address
Cardiology Division of Indonesian University
Internal
Medicine
Department
Medical
Faculty.
Ciptomangunkusumo
National
General Hospital, Jl. Diponegoro No. 71,
Jakarta, Indonesia

Details of current appointment
Employer/source of funding
Tenure
Grade/Status
Date of entry to current
grade
Previous training and experience in clinical cardiology and electrophysiology (if
any):
1998
Research Felllow in Microcirculation, National Cardiovascular Center, Osaka,
Japan
1999

Fellowship in Interventional Cardiology, Toranomon Hospital, Tokyo, Japan
1

2001-2002 Fellowship in Electrophysiology and Pacing. Kuala Lumpur. Malaysia 2004 Fellowship in Interventional Cardiology. explain how this problem will be solved (e. Malaysia 2007-2011 Phd in medical faculty of University of Indonesia. National Heart Institute. National Heart Institute. Jakarta. Indonesia Fluency in English: Native English speaker___ Fluent ____ Good ____ Poor ____ If poor.g. interpreter) A brief description of why the applicant feels they would benefit from the US Immersion Program: Details of other awards or grants for which you are currently applying: Contact address for APHRS correspondence: (Delete as appropriate and give complete address) Type of address: Home / Work Address: Day-time phone number: Email: Insurance status (sickness and accident): . Kuala Lumpur.

the applicant’s information will be shared with HRS and the sponsor. Medtronic. If application is successful. . APHRS may send information about its activities from time to time.Signature Date Unless otherwise informed.