RS. 100.00/-

 
 

 

 

 

Passport size recent Photograph duly signed by the applicant

 
 
Serial No. 00/M|F

 

 

APPLICATION FORM

INDIAN ACADEMY OF
OBSTETRICS & GYNECOLOGY,

DIBRUGARH. INDIA.

Date of Application: ……………………………………………

Application Number: ……………………………………………

 

 

PLEASE FILL THE FORM GIVEN BELOW

 

  1. Name is full: ……………………………………………………………………………..
    (In Capital Letters)

 

  1. Official Designation: ……………………………………………………………………

 

  1. Name of the Medical College: …………………………………………………………

 

  1. Years of service:……………………………………………………………………….

 

  1. Residential Address: ……………………………………………………………………..
    …………………………………………………………………………………………………
    …………………………………………………………………………………………………
    ……..…………………………………………………………………………………………

 

  1. Pin Code: ………………………………………. 7. State: ……………………………

 

  1. Town/City: …………………………………….. 9. Country: ………………………

 

  1. Telephone (with STD code):

I. Resident: ………………………………………..

                                                    II. Office: ………………………………………….

  1. Fax:

     I. Resident: ………………..…………………………………………………………

               II. Office: ……………….……………………………………………………………

 

  1. Mobile:………………………………………… 13. Pager: ……………………………

 

  1. E-mail: ……………………………………….. 15. Web Site: …………………………

 

  1.  Date of Birth: …………………………………. 17.  Place and State of Birth: …………………….

 

  1.  Gender of Applicant: …………………………  19. Marital Status: ……………………………….

 

  1.  Nationality of the Applicant: ………………………………………………………………………

       
SIGNATURE OF THE APPLICANT WITH DATE. ……………………………………..

 

  1. Qualifications of the applicant:

Qualifications

Years

Institution
1. M.B.B.S.    
2. D.G.O    
3. M.D.    
4.    
5.    

 

  1. Employment details:

 

Employment

Duration

Institution
1. PRCA/ Rotating Internship    
2. Housemanship    
3.  Register/ Resident Surgeon    
4. Residency
    Junior:
    Senior:		    
5. Assistant Professor/ Lecturer    
6. Associate Professor/ Reader    
7. Professor    
8. Professor & Head of the department    
9.    

 

 

  1. Publications:
    • National:

1. ……………………………………………………………………………………………………

2. ……………………………………………………………………………………………………

3. ……………………………………………………………………………………………………

(Enclosed in extra sheet.)

·         International:

1. ……………………………………………………………………………………………………..

2. ……………………………………………………………………………………………………..

3. ……………………………………………………………………………………………………..

(Enclosed in extra sheet.)

 

  1. Thesis:

              Self M.D. thesis

              Name of the subject: ……………………………………………………………………….

              Under University: ………………………………………………………………………….

              In the year: …………………………………………………………………………………

              

               Thesis guided by you:  1.

                                                        2.

                                                        3.

              (Enclosed in extra sheet.)

      

 

  1. Examination ship:

Undergraduate

 

Period

University
Internal    
External    

 

Post graduate

 

Period

University

Internal

 

 

External

 

 

 

  1. Seminar/Conference:

National

Period

Delegate

Chairman
     
     
     
     

 

International

Period

Delegate

Chairman
     
     
     
     

 

  1. If any other activities:

                                                               i.       

                                                              ii.       

                                                            iii.       

                                                            iv.       

                                                             v.       

                                                            vi.       

                                                          vii.       

                                                         viii.       

                                                             ix.       

                                                              x.       

 

 

 

  1. Evolution fee for the application
SL. No.

DD/CR

 Issuing Office Value (Rs.)
 

No.

  

Date
 

 

 

    

 

Signature of the Applicant with date

………………………………………

………………………………………

 

 


INSTRUCTIONS TO APPLICANT FOR THE APPLICATION

 

  1. All applications should be sent to the following address:

    Prof. S. N. R. Patgiri,
    S.K. Bhawan, Ambikagiri Nagar, Zoo Road,
    Guwahati - 781024 (Assam) India.
    Tel: 9435030289
  2. Applicant should send the applications by Register Post (A.D.).
  3. Application fee should be send by Demand Draft (D/D).
  4. Application fee once received shall not be refunded.
  5. Applicants applying from outside India should also send their application fee along with their applications. The amount of application fee must not fall short of prescribed fee when application fee is converted in Indian currency.
  6. The demand draft should be payable to “Indian Academy Of Obstetrics & Gynecology, Dibrugarh”.
  7. Indian Academy Of Obstetrics & Gynecology reserves the right to reject or accept the application for evolution. The application fee if rejected shall not be refunded.
  8. Application should be accompanied with a certificate from Professor & Head of the Department of Obstetrics & Gynecology of his/her working Medical College.

 

 

JJJ