Application for Admission Felowship in HIV Medicine - 2014

7/27/2019 Application for Admission Felowship in HIV Medicine - 2014

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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA

APPLICATION FORM FOR FELLOWSHIP IN HIV

PART - A

1.Applicants full name: (in capital letters)

______________ ___________________ __________________

(First name) (Middle name) (Family name)

2. Date of Birth & Age: ______ years. 3. e!: M " F

D M #

4. $eligion: %aste: ationality:

5.%omplete mailing (postal) address including pin code:

______________________________________________________________

______________________________________________________________

6. 'elephone numers:

a. and line: . Moile numer

.*ermanent address of applicant:

!.+,mail address: ____________________________________

".+D-%A'/A 0-AF%A'/:

l.o D+1$++2 *+%AA'/ 2 -+$'# Month & #ear of *assing

From 'o

UG

PG

O#$%&

Affix recentpassport

Size Photo dulyattested bygazetted

officer / HeadOf the

Department


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Page 1

Fellowship Program in HIV Medicine , RGUHS, Bangalore

1'. Date of %ompletion of %ompulsary

$otatory nternship and

%ouncil $egistration umer:

11. D%()&*+% & &/%0*/%3%# * HIV0AIDS )&% ( gi4e details of ho5 longyou ha4e een in4ol4ed2 descrie // HIV &%/#% )#**#*%( including clinical care2

staff training2 organi6ing programmes2 administrati4e responsiilities and

net5or7ing 5ith 1/s as appropriate.)

12. 8/$9 +*+$+%+:

*lease pro4ide details of your 5or7 e!perience 5ith the last three hospitals"organi6ations that youha4e 5or7ed for2 starting 5ith the present organi6ation. n case you are currently 5or7ing in more

than one hospital (part time)2 please specify.

S/ N N3% #$% *(#*##*0$(7*#/ P(*#* F&3 T

18. Are you n,ser4ice %andidate :

f yes furnish the information in Anne!ure ,

14. 8hy do you 5ant to underta7e the Fello5ship in ; Medicine course< ;o5

5ill it enefit yourself and your organi6ation " hospital


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Page 2

Fellowship Program in HIV Medicine , RGUHS, Bangalore

15. Application Fee details:

DD Amount________ D D o.________ Date __________ Ban7 _________

16.$eferences

Minimum = references to e included. *rescried form ( Anne!ure )should e

used.

F*(# R%%&%% S%) R%%&%%

ame ame

*osition *osition

Address

'elephone"+mail

Address

'elephone "+mail

1. DECLARATION

herey solemnly and sincerely affirm that the statements made and information furnished y mein the application form and also in the enclosures sumitted y me are true and correct. ha4e not

delierately concealed any information. hould it ho5e4er e found that any informationfurnished therein fraudulent2 incorrect or untrue in material particulars2 reali6e that am liale tocriminal prosecution and also agree to forego my seat in the college2 further that the selection and

admission to the Fello5ship %ourse is liale to e cancelled2 agree to aide y the $ules and

$egulations prescried for the same y the 1o4ernment2 nstitution2 -ni4ersity from time to time.

S*9#&% #$% C*#%

*lace:

Date :


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Page 3

A%:&% I

$eference Form for ; Fello5ship

*lease complete all sections. *lease 5rite in loc7 letters

A77/*)# I&3#*

Full ame

For ho5 long ha4e you 7no5n the applicant

n 5hat capacity do you 7no5 the applicant

R%%&%% I&3#*

ame

*osition

/rgani6ation

%ontact nfo

ignature

Date:

*lease assess the candidate on a scale of > (highest) to ? (lo5est) in relationto the follo5ing criteria

E:)%//%#

V%&

G G F*& P&

5 4 8 2 1

ntellectual Aility

%ommunication 7ills

Aility to meet Deadlines

Aility to /rgani6e 8or7loads

Aility to 8or7 ndependently

Aility to *roduce /riginal 8or7

Moti4ation

%linical 7ills

*atient Management 7ills

*ulic ;ealth %oncern


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Any /ther

O%&// S)&%

*lease comment in 5riting aout the applicant2 5hich can include suitaility to the course andaility to complete it.


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ANNE;URE < II

IN-SERVICE CANDIDATES

'he follo5ing information pro4ided y the candidate should e 4erified and for5arded y the

concerned ;ead of the Department.

?. Department :

=. *resent place of 5or7ing :

3. Date of @oining the er4ice :

. *roationary *eriod Declared or ot :

>. *roationary *eriod Declared Date :

. Doing *1 Deg. " Dip. %ourse :

C. *1 Degree Doing " Done :

. Date of completion of *1 Degree :

E. *1 Diploma Doing " Done :

?. Date of completion of *1 Dip. :

??. pecialty in 5hich he " she 5or7ing :

?=. 8hether any enGuiry is pending against him"her :

?3. 8hether he " she under suspension :

?. 8hether he " she is under unauthori6ed asence :

?>. $emar7s2 if any :

S*9#&% #$% C*#%

*lace:Date :

%ertified that the particulars furnished ao4e ha4e een 4erified and found correct and he"she is

eligile to apply the Fello5ship *rogramme in ;.

S*9#&% #$% H% #$% D%7%# =*#$ (%/

Documents

Application for Admission Felowship in HIV Medicine - 2014