Local IN Fellowship Form First Name Family Name Address Hospital where you currently work ( Private practice / Academic Institution / Government Hospital ): Medical Degree Member of Malaysian Society of Diasgnostic and Interventional Nephrology (MSDIN)? Yes No Have you completed the local Nephrology Fellowship? Yes No Email Address Mobile Phone Previous experience in Interventional Nephrology training Vascular Access Ultrasound Dialysis Catheter Procedures Kidney Biopsy Endovascular Interventions AV Access Creation IntervenIonal Nephrology courses Suggested Date Communications/lectures/presentations in national/international congresses and conferences (attach supporting documents) Publications in interventional nephrology in national/international journals (attach supporting documents) Please submit this form and your CV (attach supporting document) Submit
