Format for Submission of Bio - Data of The Nominee for Consideration for Award of Fellowship of Indian College of Physicians.
For any queries, please email at api.hdo@gmail.com or call at - (022) 6666 3224.
Please mention NA in case of no information available for any point.
For uploading documents maximum size allowed is 2MB.
Format of file name for uploading documents
Your name_document name (e.g. Dr_xyz_pg_degree_certificate.png)
1. Name in Full(Surname First)(in Block Letters): *
2.(a) API Membership Number: *
2.(b) Date of Joining *
3. Date of Birth: *
Upload your latest photograph *
Address Residence: *
Address Office: *
4
Telephone:
Mobile: *
Email: *
5
Postgraduate degree in Medicine: *
Year of passing:*
Institute:*
University:*
Attach Certificates :*
6
Experience in Medical Profession after Postgratuation in Medicine:
Name of Hospital/Clinic/Organisation & Location:
Add MoreNumber of Beds (if applicable):
Post held:
Period Served year wise (From):
Period Served year wise (To):
7
Publications: List below. (If number of publications in Journals exceeds 8, publications which can qualify as research papers may be listed under Research section 9.)
a. Number of Publications in Indexed National / International Journals:
b. Number of Chapter in Books / monograms:
c. Editorship of National level or State level: Book /Monogram/Update Series:
8
Honours And Awards
(a) Oration in National / State Association Meeting
8. (b) Award National / International / or State level
9
Research work (list below)
(a) Research sanctioned & funded by Research Agency
Attach Letter of sanction
(b) Departmental Research. (To qualify, the findings should be published in National/International Journal) Do not include papers already listed under Publications
Attach title page / Abstract
10
Contribution to API (list below and attach proof)
Post held in Organisation/Meeting:
Add MoreName of Organisation/Meeting/CME:
National/Zonal/Under API/ICP State level:
Year:
Attach Proof
11
Participation in CME or Scientific Sessions of API or ICP as Faculty:
12
Social welfare / Community service. (Include under the headings given below, with documentry evidence)
(a) Emergency services during National calamities (Quakes/Floods/Cyclones,etc)
(b) Public education Programme (Radio), TV talk/writing in news papers.
(c) Service in Rural Areas
Service:
Add MoreEvidence:
Indian College of Physicians Citation
Please share the details of two proposers for recommendation:
Proposer 1:
Name:*
Fellowship No.:*
Email:*
Mobile No.:*
Proposer 2:
Name:*
Fellowship No.:*
Email:*
Mobile No.:*
Note: Once you submit the form - emails will be sent to both the proposer for their acceptance or rejection for recommendation.
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