APPLICATION FORM FOR PCP FELLOW STATUS Please enable JavaScript in your browser to complete this form.IMPORTANT REMINDERS: - Eligible applicants are those who have been conferred as PCP Diplomates in 2022 or earlier - DEADLINE OF SUBMISSION: December 15, 2024 at 5:00 pm (NO FURTHER EXTENSIONS). - All fields with the red asterisk(*) require an input. - All fields without asterisk are optional. - Please enter valid and correct e-mail address and contact number. - Only files in JPEG (*.jpg) and PDF(*.pdf) format can be accepted by the system - Before leaving the site or closing your browser, please wait for the confirmation message, "Thank you, Doctor. Your application form has been submitted for approval." This will assure you that your submission has been successful.REQUIREMENTS FOR APPLICATION AS PCP FELLOW (Effective October 16, 2024)INSTRUCTIONS on How to Apply for the Fellowship status at PCP: 1. Please download the 2023 edition of the PCP Profile Brochure and read the Implementing Rules and Regulation (IRR) for the Committee on Credentials and Membership. Please click on this link: PCP Profile Brochure 2023 Edition 2. All documents & requirements must be submitted via the website on or before 5:00 PM (Philippine Standard Time) of December 15, 2024. 3. Incomplete documents will NOT be processed. 4. Receipt of the Application will be acknowledged via e-mail. 5. Upon validation, approval of the application by the Chair of the Committee on Credentials & Membership shall be sent to the applicant via e-mail. I. NAME OF APPLICANTLast Name : *First Name : *Middle Initial : Suffix : II. REQUIREMENTSRequirement 1-A: * Click or drag a file to this area to upload. 1-A. Current PCP-Certificate of Good Standing issued by your respective local chapter. (Please attach .JPEG or PDF. 1mb file limit) Requirement 1-B: * Click or drag files to this area to upload. You can upload up to 6 files. 1-B. Must have fulfilled the minimum required fifteen (15) PCP CPD units per fiscal year, or cumulatively earned at least thirty (30) PCP CPD units in the last 2 years. (Please attach .JPEG or PDF. 6mb file limit) Requirement 2: * Click or drag a file to this area to upload. 2. Letter of Intent to be a Fellow of the College, addressed to the President of the PCP. (Please attach .JPEG or PDF. 1mb file limit) Requirement 3: * Click or drag a file to this area to upload. 3. High-resolution (300 dpi) photo in black business attire with white background. Photo must have been taken within the last 6 months. (Please attach .JPEG or PDF. 1mb file limit) Requirement 4: * Click or drag a file to this area to upload. 4. Proof of payment for annual dues for FY 2024-2025 (Php 2,250) and processing fee (Php 1,500). (Please attach .JPEG or PDF. Maximum 1 MB file limit) INSTRUCTIONS: For those paying over-the-counter in the bank, please use and fill up the BILLS PAYMENT FORM, and input your PRC ID number as the reference number (Union Bank Pasig Branch. In favor of: Philippine College of Physicians). For those paying online, please use the PCP online payment system. Under Payment, please check "PCP Annual Dues" and "Application Fee." Then select "Diplomate - Php 2,250.00" and "Application Fee - Php 1,500.00". LINK: PCP Online Payment SystemRequirement 5: (Upload 2 Letter/File) * Click or drag files to this area to upload. You can upload up to 2 files. 5. Endorsement letters from two (2) PCP Fellows who are in good standing. Endorsement Letter for PCP Fellowship Template Pls. attach your copy of letters in JPG or PDF format, 1mb file limit) Requirement 6: * Click or drag a file to this area to upload. 6. Photocopy of PCP Diplomate Board Certificate. (Please attach .JPEG or PDF. 1mb file limit) Requirement 7: * Click or drag a file to this area to upload. 7. Certification of ANY of the following accomplishments: ~ Subspecialty Fellowship Training OR Masteral/Academic Training ~ Certificate of active Internal Medicine practice and/or teaching (signed by the Clinic or Hospital Medical Director/ Dean) ~ Completed research/es during the prescribed period (copy of abstract). ~ Certificate of Employment for a health-related administrative position, be it in government and/or private medical institution. (Please attach .JPEG or PDF. Maximum 1 MB file limit) Requirement 8: * Click or drag a file to this area to upload. 8. List of active participation in PCP-related and/or local civic activities during the last two years. This list must be verified by your Chapter President and signed by the applicant to attest to its veracity. Please refer to the Pro-Forma Template: ProForma_Letter_for_ListofActiveParticipation_v2024 (Please attach .JPEG or PDF. 1mb file limit)Requirement 9: * Click or drag a file to this area to upload. 9. Scanned copy of PMA Membership Certificate or valid PMA ID. (Please attach .JPEG or PDF. 1mb file limit)FOR INQUIRIES: The Secretariat: Philippine College of Physicians, 22nd Floor, One San Miguel Avenue Building, San Miguel Avenue corner Shaw Boulevard, Ortigas Centre, Pasig City 1605; Tel. No. 8650-4146 PCP Website: www.pcp.org.ph E-mail address: secretariat@pcp.org.ph or membershipcomsec.pcp@gmail.com PERSONAL DATAPCP CHAPTER WHERE I AM A MEMBER OF: *SELECT CHAPTERBicol ChapterBohol ChapterCAMANAVA ChapterCapiz-Aklan ChapterCaraga ChapterCentral Luzon ChapterCentral Visayas ChapterEastern Visayas ChapterIlocos-Abra ChapterLower-Northeastern Luzon ChapterManila ChapterMarikina ChapterMATAPAT ChapterNegros Occidental ChapterNegros Oriental ChapterNorthern Luzon ChapterNorthern Mindanao ChapterNorthwestern Luzon ChapterNorthwestern Mindanao ChapterPAMUNLAS ChapterPasay ChapterPASJMAN ChapterQuezon City ChapterRizal ChapterSOCCSKARGEN ChapterSouthern Luzon ChapterSouthern Mindanao ChapterUpper-Northeastern Luzon ChapterWestern Mindanao ChapterWestern Visayas-Panay ChapterLast Name: *First Name: *Middle Initial: Suffix :Date of Birth *Place of Birth: *Gender: *Select GenderMaleFemaleMarital Status: *Select StatusSingleMarriedSeparated/AnnuledWidow/WidowerName of Spouse:Email *EmailConfirm EmailMobile Number: *PCP Number: *PRC Number: *PMA Number: *OFFICE ADDRESSOFFICE NAME: *Street, Barangay: *Town/City: *Zip Code: *Tel. Number: *Region: *Select RegionNCRCARRegion IRegion IIRegion IIIRegion IV-AMIMAROPARegion VRegion VIRegion VIIRegion VIIIRegion IXRegion XRegion XIRegion XIIRegion XIIIRegion XVIII / NIRARMMHOME ADDRESSStreet, Barangay: *Town/City: *Zip Code: *Tel. Number: *Region *NCRCARRegion IRegion IIRegion IIIRegion IV-AMIMAROPARegion VRegion VIRegion VIIRegion VIIIRegion IXRegion XRegion XIRegion XIIRegion XIIIRegion XVIII / NIRARMMMailing Address: *OfficeHomePOSTGRADUATE TRAINING( * Any training pursued after earning Diplomate status)Institution - Year Level 1: *Date FROM: *FROMDate TO: *TOInstitution - Year Level 2: *Date FROM: *FROMDate TO: *TOInstitution - Year Level 3: *Date FROM: *Date TO: *TO In case a candidate trained in 2-3 different institutions, he/she must submit 'certified true copies' of both the diploma of completion of subspecialty/masteral/academic training programs and a letter of certification that he/she has satisfactorily completed a particular year level of training program from another institution. The Committee on Membership & Credentialing reserves the right to disapprove any applicant who shall be found to be deficient in his/her qualifications OR who would be found to have submitted fraudulent documents.Submit