Republic of the Philippines

Department of Health
EAST AVENUE MEDICAL CENTER
TOXICOLOGY REFERRAL AND TRAINING CENTER
The National Specialty Center for Toxicology
3rd Floor, Toxicology Wing, ER – Trauma Complex
East Avenue, Diliman, Quezon City

POSTGRADUATE COURSE ON ANALYTICAL TOXICOLOGY

NOMINATION FORM

REQUIREMENTS:

1. Must be a Registered Medical Technologist / Chemist with at least two (2) years in service;
2. Updated Professional Regulation Commission (PRC) license and curriculum vitae;
3. Accomplished Nomination Form

I. PERSONAL DATA:

Name of Nominee: __________________________________________________________________

Institution: ________________________________________________________________________
Age: _____ Sex: _____ Plantilla Position: _______________________________________________
Area of Designation: ________________________________________________________________
Number of Years in Service: __________________________________________________________

_________________________________
Signature of Nominee over Printed Name

II. JUSTIFICATION/RECOMMENDATION:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

Recommended by:

____________________________
Name and Signature of Supervisor
Date: _______________________

Approved by:

____________________________________
Name and Signature of Medical Center Chief
Date: _______________________________