Application form

For ICOG Certification Course in Reproductive Medicine

Criteria : 1) Candidate should be FOGSI Member.
2) MD or equivalent or MBBS enrolled for some PG course can be
enrolled.
Recognised Centres : (Please click here)

Dr. Biniwale Parag,Pune Dr. Patil Madhuri , Bangalore

Dr. Gupte Sanjay Anant, Pune Dr. Roy Shanti, Patna
Dr. Jirge Padma Rekha, Kolhapur Dr. Shah Duru Sushil, Mumbai
Dr. Kannan Jayam,Trichy Dr.Tandulwadkar Sunita, Pune
Dr. Malhotra Narendra, Agra Dr. Thakur Ratna,Indore
Dr. Nadkarni, Purnima, Surat Dr.Trivedi Prakash, Mumbai
Dr. Parihar Mandakini, Mumbai Dr. Nadkarni Purnima,Surat

Training Fees : DD of Rs.60,000/- for 6 months Training Period : 6 months

Passport
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Name of the Candidate : _______________________________________________________

(Surname) (First Name) (Middle Name)

Qualification : ___________________________________________________

Mailing Address : _______________________________________________________

________________________________________________________________________

Contact Numbers : _________________ ___________________

Mobile _________________

Email ID : _________________________

Member of the Society : ___________________________________________________

I am enclosing herewith Demand Draft No.________________ dated ______________ for

Rs.60,000/- drawn on _________________ Bank in favour of FOGSI towards the Training
Fees of Certification Course in Reproductive Medicine.

Thanking you,

_________________
Signature of Candidate

(For Centre Only)

Training Period : From _________________ to ____________________

_________________
Signature of Trainer