APPLICATION FORM FOR PERMISSION TO ATTEND A NATIONAL

CONFERENCE/WORKSHOP/SEMINAR/CONVENTION

1. Personal No Rank, Name : DR 10500L Col Amit Khattak

2. Appointment : Classified specialist (Prosthodontics)
3. Speciality : Prosthodontics and Crown & Bridge
4. Sub Speciality (if applicable) : Nil
5. Email id & Mobile No. : captkhat@rediffmail.com, 8131006641
6. Unit : ADC (R&R)
7. Name of conference (Brochure to be att) : 51st IPS Conference
8. Venue Dr. Shyama Prasad Mukharjee Stadium, Goa
9. Date (s) of conference : 07 to 10 Dec 2023
10. Applied for attendance as : (a) Official Delegate
(b) Member delegate
(c) Own arrangements on entitled leave
11. Amount of delegation fees to be paid : Conference : Rs -14514
CME : Rs -00.
Workshop : Rs -00.
Any Other : Rs- 14514.00.
Total Rs – 14514.00
12. Name of Association/ Society & Serial No in : Indian Prosthodontic Society 6.3
DGAFMS approved list
13. Individual Membership No of Association/ Society : OL 1460
Indian Prosthodontic Society
14. Attending in which capacity : Presenting a paper in PCC
Chairing a session
Participating in panel discussion/workshop
Invited Award/Guest lecture/Oration
Participation in quiz
Delegate only
Any other
15. Title of paper to be presented (Enclose abstract : Implant impressions - A Contemporary Approach
& certificate countersigned by Commandant/CO/
as per SAO 3/S/2001/M1)
16. Acceptance of paper by organizers : Enclosed / Not Enclosed
17. Paper/poster is based on a funded AFMS : No
research project
 2

18. Details of conference (s) applied during the same calendar year (01 Jan to 31 Dec 2023):
(a) Name of Conference : Nil
(b) Venue & Date : -
(c) Sanction accorded vide letter No : -
(d) Official delegate/ Member delegate/At own : -
expense on entitled leave

Date: Signature of Officer

19. RECOMMENDATION OF COMMAND DENTAL ADVISOR (SC)

Recommended/Not Recommended

Date: 2023

20. RECOMMENDATION OF MG MED, MG&G AREA

Recommended/Not Recommended

Date: 2023

21. RECOMMENDATION OF DGDS, IHQ OF MOD(ARMY), NEW DELHI

 Recommended/Not Recommended

Date: 2023

22. RECOMMENDATION OF DGMS (ARMY), IHQ OF MOD(ARMY), NEW

DELHI

Recommended/Not Recommended

Date: 2023

23. RECOMMENDATION OF DGAFMS, IHQ OF MOD(ARMY), NEW

DELHI

Recommended/Not Recommended

Date: 2023
 (Refer Para 21 of SAO
3/S/2001/MI)

AUTHOR’S CERTIFICATE FOR PRESENTATION OF PCC AT

NATIONAL CONFERENCE

I certify that “I have not used any official information and/or material or any information
obtained by me in my official capacity in presenting PCC titled “Implant impressions - A
Contemporary Approach” by me at 51st IPS Conference, Goa from 07th – 10th Dec 2023.

Station : Nashik (Amit Khattak)

Date: 2023 Col

COUNTERSIGNATURE & NO OBJECTION CERTIFICATE

I certify that I have perused the PCC titled “Implant impressions - A Contemporary
Approach” submitted by Col Amit Khattak and I have no objection to it being presented in the
51st IPS Conference, Goa from 07th -10th Dec 2023.

Place: Pune (SK Bhandari)

Maj Gen
Dated: 2023 Commandant &
Comd Dental Adv (SC)
 CERTIFICATE FOR ATTENDANCE AT NATIONALCONFERENCE

1. I, DR 10500L Col Amit Khattak, will not use any information and material from official
documents graded ‘RESTRICTED’ or above or any classified documents obtained by me in any
official capacity during 51st IPS Conference, Goa from 07th -10th Dec 2023.

2. The above presentation is not based on AFMRC project

Station : Nashik (Amit Khattak)

Date: 2023 Col

COUNTERSIGNATURE BY COMDT & COMD DENTAL ADVISOR (SC)

Place: Pune (SK Bhandari)

Maj Gen
Dated: 2023 Commandant &
Comd Dental Adv (SC)