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    Clinical Fellowship ANNEXURE B

    Uploaded by

    Navin Chandar
    This document is an application form for a clinical fellowship at Apollo Hospital. It requests information such as the applicant's personal details, educational qualifications, experience, a declaration agreeing to the terms of training, and a checklist of required documents. The form collects the applicant's name, address, date of birth, medical council registration numbers, educational history, publications, work experience, and a signed declaration of acceptance of the hospital's code of conduct and rules.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Clinical Fellowship ANNEXURE B

    Uploaded by

    Navin Chandar
    57 views3 pages
    This document is an application form for a clinical fellowship at Apollo Hospital. It requests information such as the applicant's personal details, educational qualifications, experience, a declaration agreeing to the terms of training, and a checklist of required documents. The form collects the applicant's name, address, date of birth, medical council registration numbers, educational history, publications, work experience, and a signed declaration of acceptance of the hospital's code of conduct and rules.

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    Clinical-Fellowship-ANNEXURE-B

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    This document is an application form for a clinical fellowship at Apollo Hospital. It requests information such as the applicant's personal details, educational qualifications, experience, a declaration agreeing to the terms of training, and a checklist of required documents. The form collects the applicant's name, address, date of birth, medical council registration numbers, educational history, publications, work experience, and a signed declaration of acceptance of the hospital's code of conduct and rules.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    57 views3 pages

    Clinical Fellowship ANNEXURE B

    Uploaded by

    Navin Chandar
    This document is an application form for a clinical fellowship at Apollo Hospital. It requests information such as the applicant's personal details, educational qualifications, experience, a declaration agreeing to the terms of training, and a checklist of required documents. The form collects the applicant's name, address, date of birth, medical council registration numbers, educational history, publications, work experience, and a signed declaration of acceptance of the hospital's code of conduct and rules.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    ANNEXURE B (For the candidate)

    Location of Apollo Hospital................................................................................................................


    Clinical fellowship applied for.............................................................................................................
    Speciality........................................................................................................................................... Photograph
    Duration of Clinical fellowship……………………………………………………………………………………………………..
    Name of Consultant/ Guide………………………………………………………………………………………………………

    PERSONAL PARTICULARS

    1. (a) Name (in capital letters) (as appearing in MBBS certificate)

    (b) Father's / Husband's Name & Occupation

    (c) Reg. No. of State/ Delhi Medical Council Dated

    (d) Reg. No. of MCI Dated

    3. Date of Birth (as per Matriculation Certificate)

    D D M M Y Y Y Y

    4. Address for correspondence.


    Name...............................................................................................................................................................
    Address………………………………………………………………………………………………………
    ………………………………………………………………………………………………………………

    Pin------
    Telephone No.(Residence)…………………………… Mobile No ………………………………………
    E-Mail………………………………………………………………………………………………...

    -1-
    5. Permanent Address:-

    Name............................................................................................................................................................

    Address…………………………………………………………………………………………………….

    ……………………………………………………………………………………………………………..

    Pin------

    Telephone No.(Residence)…………………………… Mobile No ………………………………………

    E-Mail………………………………………………………………………………………………..

    6. Educational Qualifications:-

    Examination Passed Name of university /Board / Year of Passing %/ Marks


    State
    1. M.B.B.S.

    2. MD/MS/DNB

    3.Others

    b). Papers published (i) ……………………………………………………….

    (ii)……………………………………………………….

    (iii)……………………………………………………….

    (iv)……………………………………………………….

    7. Experience/Details of employment (as per format)

    Speciality/ Discipline/ Name of the Hospital Designation Period Total


    Department From To Period

    -2-
    8. I hereby declare that

    a. Particulars given in this application form are true and accurate to the best of my knowledge and belief.
    b. I hereby undertake to abide with and strictly follow the code of conduct and discipline of the hospital.
    c. I agree to undergo the training in the course applied for, and, undertake to abide with the Rules & Regulations of
    Apollo Hospitals.
    d. Any change in my personal particulars given above will be notified immediately on occurrence to the Academic
    Advisor office of the Hospital.
    e. Joining of the candidate is subject to his/her medical fitness. The medical examination of the candidate shall be done
    by the Medical Board of this hospital/institute. Candidate found fit in the medical examination shall only be allowed
    to join the clinical fellowship.

    _________________________________ _____________________________
    Candidate Name in block letters Signature of the Candidate

    Date: / / (Use only Blue /Black Ballpoint Pen)

    CHECK-LIST OF DOCUMENTS REQUIRED TO BE ATTACHED WITH THIS FORM

    Please enclose attested copies by a Gazetted Officer/Self Attested of the following certificates with your application in the
    order given below:
    a). M.B.B.S. Degree & all Mark sheet
    b). MD/MS/DNB/ MCh( as applicable)
    c). Self-attested copies of Matriculation / Higher Secondary certificate/ Driving Licence/ Passport showing date of
    birth.
    d). Registration Certificate of State Medical Council.
    e). Two passport size photographs

    -3-

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