Application Form for Fellowship

Note: * Mandatory Fields
Fellowship program interested in*
1. Personal Data
Name*
Father/Spouse Name*
Present Address*
Phone
Mobile*
Email*
 Same as present address
Permanent Address*
Id Proof
Date of Birth
Place of Birth
Gender
District
State
Nationality
Marital Status
2. Present Employment
Institution
Designation
Nature of Work & Responsibilities
Employment Type
3. Qualification
Examination Passed Institution Year of Passing Division
MBBS
DO/DOMS
MS/MD/Dip.NB
4. Work experience (Past)
S.no. Organization From To Designation
1
5. Surgical Experience (During last 3 years)
Total No of Cataract surgeries
ECCE With IOL
SICS
PHACO
OTHER SURGERIES
6. PROFESSIONAL REGISTRATION DETAILS
ORGANISATION CERTIFICATE NUMBER DATE
7. Name, address & designation of 2 persons not related to you, whom we can contact for reference
Name Address Designation
8. Preferred dates to begin training program
Upload Your Resume *

* Please upload resume in doc,pdf,docx,txt format only , Maximum upload size upto 300KB.
Peer Reviewed Publications (If Any)
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