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23
rd
- 25
th
August 2024
India Habitat Centre, New Delhi
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Archive
Application form - Mentorship Program
Personal and Academic details
Mentorship Program
*
Please Select
DR. SANJIV KANDHARI MENTORSHIP
PROF. ARUN K SINGH MENTORSHIP
DR. R D MUKHIJA MENTORSHIP
DR. NITI KHUNGER MENTORSHIP
DR. MANAS CHATTERJEE MENTORSHIP
DR. SOMESH GUPTA MENTORSHIP
Name
*
Date of birth
*
Age in completed years
*
Correspondence email
*
Correspondence address
*
Home Phone Number
*
Mobile Number
*
Status (Resident/Faculty in Medical College/Independent practicing consultant)
*
Membership number, years of membership of their respective society (Dermatology/ Plastic Surgery)
*
Please tick on the Mentorship program you wish to apply for
*
Surgery
Non Surgery
Academic Details
Year of Passing MBBS/ Institution
*
Postgraduate qualification (MD/Mch/DNB) / year of passing / institution
*
Post qualification experience and current position
*
Details of congress
Conference registration number
*
*Registration receipt to be attached/ if not yet registered please provide once you are registered – until we receive this we cannot grant the scholarship
Resume
*
Allowed Formats (Max: 3MB)
PDF / DOC / DOCX / TXT
Upload proof of last 2 year's Presentation and Publications (upto 10 allowed)
Allowed Formats: PDF / DOC / DOCX / PPT / XLS / XLSX / GIF / JPG (Max: 3MB)
Brief write up about yourself
*
Allowed Formats (Max: 3MB)
DOC / DOCX / TXT
Checklist for submitting the Form:
1. Mentorship Form
2. Detailed CV including details of publication and Presentations at conferences - oral / poster.
3. Proof of last 2 years publications and Presentations at conferences - oral / poster.
4. Brief write up on why you should be given this opportunity and what is your motivation for receiving this mentorship - (Not more than 250 words)
2018
2018
2018
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