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Application to take the IAP Neonatology Fellowship Examination
Date: _________________ |
DOWNLOAD Fellowship Examination Form |
To,
The Chairperson,
__________________________________________________,
The below mentioned fellowship candidates training at our Institute, would like to take the IAP Neonatology Chapter Fellowship Exam Scheduled on ______________ at _________________.
The details of the candidates and their exam fee payment are given below –
1) Candidate’s name - ____________________________________________________
Cell No. - _________________ Email ID: ___________________________________
IAP Membership No. - _________________ Neonatolgy Chapter Memebrship No.: _______________________________
Date of Appointment. - _________________
(Please attach a copy of the appointment letter from Institute)
Completed 85% of the prescribed period of training: Yes / No
Performance / Conduct / Internal assessment – Satisfactory / Unsatisfactory
Clinical study completed – Yes / No
Exam fee amount – Rs. 10,000/- (Ten thousand only) Transaction No: ___________________
Bank _____________________________________ Date of Transaction: __________________
2) Candidate’s name - ____________________________________________________
Cell No. - _________________ Email ID: ___________________________________
IAP Membership No. - _________________ Neonatolgy Chapter Memebrship No.: _______________________________
Date of Appointment. - _________________
(Please attach a copy of the appointment letter from Institute)
Completed 85% of the prescribed period of training: Yes / No
Performance / Conduct / Internal assessment – Satisfactory / Unsatisfactory
Clinical study completed – Yes / No
Exam fee amount – Rs. 10,000/- (Ten thousand only) Transaction No: ___________________
Bank _____________________________________ Date of Transaction: __________________
__________________________________ _____________________________
Signature of Institute Head Signature of Fellowship Coordinator
