THE PHILIPPINE COLLEGE OF HOSPITAL ADMINISTRATORS, INC.

Secretariat : Rm. 101, PMA Bldg., Brgy. Bagong Pag-Asa, North Avenue, Quezon City 1105 Tel. No. 02-924-1527

*WEBSITE http://www.pcha.org.ph/ *Email : pchainc@yahoo.com Mobile No. 0922-496-3100

APPLICATION FOR MEMBERSHIP (FELLOW)

1. NAME ___________________________________________________________________________________________________
Surname First Name Middle Name

2. PRESENT POSITION____________________________________________ DATE APPOINTED__________________________

3. INSTITUTION ______________________________________________________________ TEL. NO. _____________________

ADDRESS__________________________________________________________________________________________

E-MAIL (personal): ________________ ____________________________________

4. RESIDENCE ______________________________________________________________________________________________

_______________________________________________CIVIL STATUS_________MOBILE NO.: _______________

5. DATE OF BIRTH ______________________________________ PLACE OF BIRTH ___________________________________

6. EDUCATION:
SCHOOL DEGREE YEAR

6.1 High School __________________________________ ________________________ _______________

6.2 College __________________________________ _______________________ _______________

6.3 Post Graduate Studies __________________________________ ________________________ _______________

__________________________________ ________________________ _______________

7. PAST POSITION (List Chronologically)

LENGTH OF SERVICE
POSITION INSTITUTION & ADDRESS (DATE APPOINTED)

________________________ _________________________________________________________ ________________________

________________________ _________________________________________________________ ________________________

________________________ _________________________________________________________ ________________________

________________________ _________________________________________________________ ________________________

________________________ _________________________________________________________ ________________________

8. MEMBERSHIP IN NATIONAL AND LOCAL HOSPITAL / HEALTH ORGANIZATIONS:

NAME OF ORGANIZATION YEAR ADMITTED HIGHEST OFFICE

____________________________________________________ __________________________ ___________________________

____________________________________________________ __________________________ ___________________________

____________________________________________________ __________________________ ___________________________

____________________________________________________ __________________________ ___________________________

9. FOR NEW MEMBERS: SUBMIT –

a. Organizational chart of Hospital
b. Bed Capacity of Hospital
c. Category of Hospital
d. Job Description in the Hospital
e. Xerox copy of Complete Post-Graduate Studies
f. Xerox copy of appointment to present position 2 x 2 photo
g. I.D. photo 2” x 2” colored
h. Fees - P8,000.00
Inclusions – Initiation fee (Fellow), Review Materials,
Kit and meals (lunch, am/pm snacks
 FOR FELLOWSHIP ONLY

a. MEMBERSHIP FOR PHILIPPINE COLLEGE OF HOSPITAL ADMINISTRATORS INCORPORATED

TYPE DATE ADMITTED ACTIVE

_____________________________________ ______________________________ _____________________

_____________________________________ ______________________________ _____________________

_____________________________________ ______________________________ _____________________

b. SUBMIT PAPER PUBLISHED OR PRESENTED IN SEMINAR:

TITLE WHERE PUBLISHED / READ ISSUE

_____________________________________ ______________________________ _____________________

_____________________________________ ______________________________ _____________________

_____________________________________ ______________________________ _____________________

c. NUMBER OF YEARS ENGAGED IN HOSPITAL ADMINISTRATION

____________

REFERENCES (3 AT LEAST 2 OF WHICH ARE FELLOWS, PCHA):

NAME TITLE INSTITUTION

_____________________________________ ______________________________ _____________________

_____________________________________ ______________________________ _____________________

_____________________________________ ______________________________ _____________________

NAME TO BE USED IN RECORDS AND CERTIFICATES

________________________________________________________________________________________________________

MAILING ADDRESS: ____________________________________________________________________________________

________________________________________________________________________________________________________

SIGNED: ____________________________________________________ DATE: ____________________________________

________________________________________________________________________________________________________

DO NOT FILL UP

ACTIONS:
APPROVED DISAPPROVED

1. CREDENTIALS COMMITTEE:

2. EXAMINATION COMMITTEE:

3. BOARD OF REGENTS: