Application Form for Courses offered in Obstetric Ultrasound and Fetal Medicine

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All * are mandatory fields

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* 1. Course Opted for / interested in:

ONE YEAR - FELLOWSHIP IN OBSTETRIC ULTRASOUND (Full Time) under AEGIS of Fernandez FoundationEligibility: MD/DGO/MS/DNB/Radiology in the concerned specialty from MCI recognized institutes.Age not exceeding 45 years of the year of admissionSelection - Entrance Exam and InterviewStipend : Not Paid

TWO YEAR FELLOWSHIP IN FETAL MEDICINE (Full Time) under AEGIS of Fernandez FoundationEligibility: MD/MS/DNB in Obstetrics and Gynecology in the concerned specialty from MCI recognized institutes.Age not exceeding 45 years of the year of admissionSelection : Entrance Exam and InterviewStipend : Paid

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* 2. Details

Name

Date of Birth

Age

Gender

Address 1

Address 2

City

State

Mobile 1

Mobile 2

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* 3. Specialty

Obstetrics & Gynaecology

Radiology

Others

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* 4. Qualification

MD - OBGY

MS - OBGY

DNB - OBGY

DGO - OBGY

MD - Radiology

DNB - Radiology

DMRD

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* 5. University

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* 6. Year of Passing

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* 7. Percentage/GPA

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* 8. Remarks (If any)

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* 9. Experience

Yes

If Yes please mention years of experience.

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* 10. Research Work

Awards

Papers presented

Papers published

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* 1. Course Opted for / interested in:

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* 2. Details

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* 3. Specialty

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* 4. Qualification

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* 5. University

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* 6. Year of Passing

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* 7. Percentage/GPA

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* 8. Remarks (If any)

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* 9. Experience

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* 10. Research Work

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* 11. Describe in a few lines your present scope of work.