Ref. No.

GS_001/20

Institute of Medical & Minimal Access Surgery Training

(Please complete all the details)

Course Name: ……………………………………………….…………………. Course Date: ..........................

Surgical Specialty: …………….……………………….… State Registration No ……….……..……………….

Applicant’s Name (CAPITALS):

Residential Address: ………………………….…………………………………………………………………..

……………………………….…………………………....……………Pin Code: ……………………..….……
Mobile: …Telephone Res.: ……………….…………........................

E-mail: …

Birth Date: …...……….………..…………………………………..…… Age: ………………………………….

Latest Qualification (Degree/ Diploma) and Year of Passing: …………..…………………………………….....

Educational Institute: ………………………………....……………………… Years of experience: …...……...

Current status: Practicing PG Resident Student Teacher

Current Institute: Nursing Home Hospital Teaching Institute

Category: Private Government

Address of the current Institute /Hospital /Nursing Home: ………………………………………………………

................……………………………………………State:……………………………… Pin Code: ………….
How did you learn about IMMAST (Please Tick)?
SMS Phone Call Email Website Reference
Printed Promotional Material Facebook Instagram Linkedin
Conference Advertisement in Journal (Pls specify):……………………………………………
Are you practicing Endoscopy / Laparoscopy: Yes No

Suitability of your existing OT Set up for MAS:

Meets all requirements for MAS Needs up-gradation Not in place

Have you attended any MAS training courses previously (If yes, please provide details): …………….………
…………………………………………………………………………………………………………………..

Have you attended any courses at IMMAST previously (If yes, please provide details): ……………………..
…………………………………………………………………………………………………………………..

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 Ref. No. GS_001/20

Declarations / Affirmations:

I am not part of any department / committee / group in my current Institute / Hospital / Nursing Home or any of
its affiliates, which takes decisions on which medicinal products to purchase from the market or institution, and
even if I am, my participation herein will not influence my decision and discretion on which medicinal products
to purchase from the market or institution.

I do hereby declare and affirm that any and all training provided by IMMAST will not influence or have no
bearing on my decision to purchase/prescribe any particular medicinal products.

I do hereby declare and affirm that all course content, material, videos, images, etc. are the intellectual property
of IMMAST and I will not use the said material for any other purpose except for the training provided here at
IMMAST.

I do hereby declare and affirm that certain content, material, videos, images, ideas, etc. as identified by speakers
and lecturers at IMMAST are confidential in nature and are the Confidential Information of IMMAST, and I am
not to disclose such Confidential Information to any person except as allowed by IMMAST and such
Confidential Information is only to be used for the training provided here at IMMAST.

I do hereby declare and affirm that I do not have any conflict of interest with respect to my current roles and
responsibilities at my current Institute / Hospital / Nursing Home as against my training here at IMMAST.

I do hereby declare that no legal and/or criminal case or professional misconduct case is pending against me
before any authority/court / investigating agencies. I, further inform that I have never been found guilty /
convicted/penalized of any legal offense and/or crime by any court of law/authority in the past.

I do hereby declare and affirm that I am in compliance with all applicable anti-bribery laws (including but not
limited to those of India, the United Kingdom and the United States of America)

I do hereby declare and affirm that I am in full compliance with the Indian Medical Council (Professional
Conduct, Etiquette and Ethics) Regulations, 2002, and have never been disqualified by MCI or any regulatory
authority (including the DCGI or US FDA) from performing as an investigator or HCP or providing any duties
or with regard to any clinical trials.

I do hereby consent for IMMAST to collect, maintain & share my above mentioned information internally &
externally for regulatory, legal & collaborative purposes so as to provide better services to me in the future.
I further consent to the use of any of my photographs/videos/testimonials/creative records during the
course for IMMAST promotions and communication.

Any additional information: …………………………………………………………………………………….

……………………………………………….….………………………………………………………

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 Ref. No. GS_001/20
I do hereby declare and affirm that the above details furnished by me are all true and I will immediately
inform IMMAST in writing if any of the above relevant circumstances have changed since the signing of this form.
I do hereby declare that neither I am nor anyone in my circle of co-habitants / those I frequent meet is, suffering
from COVID or exhibiting any symptoms thereof.

I do hereby absolve and keep IMMAST and its affiliates harmless and indemnified from any liability that it may
face in regard to the statements made hereinabove or with regard to my training program. Any discrepancy or
untrue information found is liable for cancellation of registration, without refunds, and I shall be liable to
IMMAST or any third party for the same.

I understand & agree that IMMAST shall have sole discretion while granting admission/ enrolment to any course
facilitated at IMMAST.

I hereby acknowledge and confirm all the contents stated above.

___________________________
Signature

Quality Policy Statement

We develop and deliver training that emphasizes safe and standard practices for healthcare teams to enable them
to ensure optimal Patient Care. We ensure the maintenance of Quality Standards with continual improvement
through active monitoring of processes, in-house innovations, and training.

Course Disclaimer
IMMAST is purely an academic and training initiative and does not have any connection or influence in the
management or business of its holding/parent/affiliate companies or in any institute/ hospital. Course material
provided for the courses is for academic purposes only. Though every effort is taken to provide information that
is accurate and timely, IMMAST makes no guarantee in regard to diagnosing, treating, curing, mitigating, or
preventing any type of disease or medical condition. Under any and all circumstances, IMMAST will not be
held liable for any clinical/nonclinical outcomes due to advice or training to the course participants. Use of the
course material for commercial or any other purposes is strictly prohibited.

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 Ref. No. GS_001/20
Enrolment, Payments, Cancellations Postponements and Refunds Policy
• Enrolment is subject to full disclosure made by the participant to IMMAST, and IMMAST relying on
such affirmations/declarations.
• Registration for a training course at IMMAST is non-transferable.
• Payments towards Registration Fee shall not be accepted by cheque. Cash payments are strongly
discouraged. Payment in instalments is not accepted.
• Candidates wishing to postpone / cancel their registered participation for a training course can do so with
a written / email request for postponement / cancellation intimated to IMMAST up to 15 days prior to
the date of scheduled training course. Only such requests received up to 15 days prior to the date of
scheduled training course shall be eligible for postponement / cancellation. Requests for postponement
/ cancellation not meeting this criterion shall not be eligible for postponement / refund.
• In case of eligible postponement, IMMAST shall allow the registration fee to be carried forward and
adjusted towards registration fee of the same candidate for another course provided by IMMAST, on a
future date within current financial year (Current financial year is defined as beginning from 1st April of
that year to 31st March of next year). 100% of the registration fee paid shall be adjusted against the said
future course. Such a carry forward shall be allowed only once, within the current financial year per
candidate.
• Candidates seeking refund as per policy due to cancelation, must request for refund with their valid bank
account details stated in the request as well, for an electronic transfer. In case of a refund for participation
cancelled by candidate, any applicable bank charges shall be borne by the candidate seeking the said
refund.
• In case of accepted cancellation, refund of 100% registration fee paid shall be initiated from IMMAST
within 10 working days of receipt of cancellation request. Refunds shall not be made in cash.
• IMMAST reserves the right to cancel / postpone / advance a course without any notice. In case of course
cancellation by IMMAST, candidates will be provided with an option of postponement for any similar /
non-similar course. IMMAST will accommodate the candidate in the upcoming courses within the
current financial year. Candidates will also be offered an option of refund. Difference in course fee, if
any, will be paid/refunded accordingly.
• IMMAST will not be liable for any loss or any refunds/adjustments, in event of course cancellation (in
part/full) due to any natural calamity / unavoidable catastrophes. Under any circumstances, IMMAST
shall not refund any other expenses apart from the course fees paid.

I hereby acknowledge and confirm all the contents stated above.

_______________________
Signature

PLEASE NOTE THAT YOU CAN STORE YOUR VALUABLES IN SAFETY LOCKERS AVAILABLE AT IMMAST

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