@ 2=2"2=— MESIARC APPLICATION FORM for Registration as Fellowship Trainee 2012 Redefining ENT Gare Photograph Application Form No: 1. Name (CAPITAL LETTERS) (Leave a blank space between each part of the name) Father's/Husband's Name (CAPITAL LETTERS) (Leave a blank space between each part of the name Sex: [_]Male [_]Female 4. Date of Birt Medical Council Reg. No: Date of Regn 3. 5. 6. 7. Permanent Address City State 8. Address (Correspondence Address) Telephone Numbers: Home| Hospital MOB: E-mail 1D: 9. Qualifications: (Attested copies of Certificates to be attached.) Date of joining Date of completion University MBBS MS/ DIPLOMA Experience : Attach clv Publications: Conferences attended / papers presented: (Attested copies of Certificates to be attached.) 10.Elaborate briefly on why you have chosen this programme: DECLARATION & CERTIFICATION Ihere by declare and certify that: a) | have read the general instructions and the rules and regulation and shall abide by them. b) Particulars given in this application form are true and accurate to the best of my knowledge and belief. c) The documents submitted as evidence of above facts are duly attested by a Gazetted Officer d) | understand that in case any of the facts stated by me is/are found to be false or any of the documents enclosed by me is/are found to be false, | am liable to be disqualified of my fellowship or appropriate action deemed fit by MESIARC can be taken against me. e) | understand that, MESIARC. reserves the right to determine final eligibility and further reserves the right to cancel the candidature if ineligibility found at any stage. Date: Signature of the Candidate NOTE: PHOTOCOPY OF THE FILLED UP APPLICATION FORM MUST BE RETAINED BY THE CANDIDATE FOR FUTURE USE. 11. Detail of Registration Fee - Rs. Rupees DD No. DD Date: Bank Name: Details of the candidates name, hospital name and the speciality for which required to be mentioned on the reverse of draft.