Swasthya

Completed Application form should be addressed and sent to The Dean of Medical Studies, AIIDR & YDS , on or before 10th November 2008. Applications received after this date will not be entertained.

ELIGIBILITY

Practicing Family Physician

COURSE DURATION

Duration of the course will be for 6 months

Comprising

Theory classes: 4 - 8 Hours - Once a month

Learning sessions

Work Shop

Seminar

Conference etc (Non-residential)

7-15 days Clinical/ practical experience - Outpatient, Wards, Laboratory - in Rotation

Examination

Convocation

COURSE FEE

Delegate Fee Rs. 5,000/-

Educational Grant Rs. 15,000/-

Total Rs. 20,000/-(Rupees Twenty Thousand only)

A Delegate fee of Rs. 5,000/-(Rupees five Thousand only) is payable at the time of admission by Demand Draft (cheque for local payment) drawn in favour of All India Institute of Diabetes & Research” payable at Ahmedabad.
Course fee includes Admission fee, Tuition fee, Examination fee, Course material, Conference fee, Delegate fee of ISCID 2006 (Rs. 2500/-), Food Charges, other administrative expenses etc.

APPLICATION FORM

NAME :___________________________________________________ Sex: M / F

(As in certificate – in Block letters)

DATE OF BIRTH :____/____/__________ AGE:________ MARITAL STATUS______________________

PERMANENT RESIDENTIAL ADDRESS WITH TELEPHONE NUMBER (with area code)

_______________________________________________________________________________________________

ADDRESS FOR COMMUNICATION WITH TELEPHONE NUMBER:

_______________________________________________________________________________________________

E-MAIL _____________________________________________

MOTHER TONGUE__________________________________________

OTHER LANGUAGES KNOWN TO SPEAK/READ/WRITE_______________________________________________

PRESENT OCCUPATION__________________________________________________________________________

NAME & EMPLOYMENT STATUS OF THE FATHER / GAURDIAN / SPOUSE______________________________

_______________________________________________________________________________________________

QUALIFICATIONS	UNIVERSITY	YEAR OF PASSING	PERCENTAGE / CLASS	YEAR OF REGISTRATION IN THE REGIONAL MEDICAL COUNCIL WITH NUMBER

Tell us about your career goals after completion of the Certificate course (if you are selected)

____________________________________________________________________________________________

Tell us briefly why you are interested in this Certificate course and why we should consider you?

____________________________________________________________________________________________

DECLARATION

I….….....…….……………………...……………………….hereby declare that the information furnished above is true to the best of my knowledge and belief and I shall abide by the Rules and Regulations of the Institution as may be in force from time to time.

Candidate’s Signature

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