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ใบสมครเลขท………………………. เลขทสมคร ……………………..

ใบสมครเขารบการฝกอบรมเปนผมความรความช านาญ ในการประกอบวชาชพเภสชกรรม สาขาการคมครองผบรโภคดานยาและสขภาพ

หลกสตรเภสชกรรมปฐมภม : เภสชกรรมครอบครวและชมชน

ชอผสมคร (ภญ./ภก.)………………………………………………………………………………. ใบประกอบวชาชพเภสชกรรม/หรอใบประกอบโรคศลป เลขท ภ. .................................................... ทอยส าหรบการตดตอ ................................................................................................................................................................ ................................................................................................................................................................ โทรศพท ....................................... โทรสาร …………………………………โทรศพทมอถอ………………... E-mail address : ..............................................................................Line ID……………………….…. 1. ประวตสวนตว

ต าแหนงปจจบน............................................................................................................................ หนวยงาน….................................................................................................................................... ........................................................................................................................................................ โทรศพท……........................................โทรสาร……................………………

2. ประวตการศกษา ระดบการศกษา สาขาวชา สถาบน ป พ.ศ. ทไดรบ ปรญญาตร…………………………………………………….........................………………………………………………………… ปรญญาโท………………………………………………………….......................…………………………………………………….. ปรญญาเอก………………………………………………………….....................…………………………………………………….. อน ๆ………………………………………………………………….......................…………………………………………………….

วคบท 1

ตดรปถาย ขนาด 1 นว

๒

3. ประวตการท างาน สถานทประกอบวชาชพ ต าแหนง หนาทรบผดชอบ/ปฏบตชวงเวลา (ป พ.ศ. – ป พ.ศ.)

………………………………………………………………………………………………………………..………………………………………………………………………………………………………………..………………………………………………….…………………………………………………………………………….………………………………..……………………………………………………………………..………………………………………………………………………………………………...................................................... 4. สถานททปฏบตงานดานเภสชกรรมปฐมภม หรอ หนวยบรการปฐมภม (Primary Care Unit ; PCU)

หรอ เครอขายหนวยบรการปฐมภม (Network Primary Care Unit: NPCU) โรงพยาบาล............................................................................................................................ ทตง........................................................................................................................................

5. การสมครเขารบการฝกอบรมในครงน ขาพเจาขอรบรองวา 5.๑ ไดรบอนมตจากผบงคบบญชาใหเขารบการฝกอบรมเรยบรอยแลว 5.๒ ขาพเจาสามารถเขารบการฝกอบรมไดตลอดหลกสตร และ พรอมทจะปฏบตตามขอก าหนดและเงอนไขในการฝกอบรมทกประการ และ ไดรบทราบแลววา กรณทไมปฏบตตามขอก าหนดหรอเงอนไข สภาเภสชกรรม จะรายงานใหหนวยงานตนสงกดทราบ 5.3 ผบงคบบญชาไดรบทราบและอนมตใหเบกคาใชจายในการเดนทางเขาฝกอบรม และ เบยเลยงในชวงการฝกอบรมตามสทธจากหนวยงานตนสงกดตลอดหลกสตรการฝกอบรม

ลายมอชอผสมคร…………………………………..…………………. (…………………………………………………….)

ต าแหนง……………………………………………………. วนท………...เดอน…………………..พ.ศ…………