G.S.L.

GENERAL HOSPITAL
NH-16, LAKSHMIPURAM, RAJAMAHENDRAAVARAM-533 296.
(0883) 2484999, FAX : 2484888

B.P.T. INTERNSHIP – POSTINGS – TOTAL DURATION : 6 MONTHS

Name :
(In block Letters)
Photo
Age & Sex :
Date of Birth :
Address :
Present

Permanent :

Qualification :
Year of Passing :
Name of College & University :
Date of Commencement of Internship:
Period
Place of posting Duration ABSENT EXTENSIONS
From To
Physiotherapy One month
Orthopaedics One month
Neurology 15 days
Neuro surgery 15 days
Cardiology 15 days
CTVS 15 days
Gen. medicine 15 days
Gen. surgery 15 days
Community based
One month
Rehabilitation / Geriatics
TOTAL NUMBER OF ABSENT DAYS:_______
TOTAL NUMBER OF EXTENSIONS:________

Date: Signature