Enrollment Form for Participants
APPLICATION FORM FOR ENROLLMENT IN
CERTIFICATE COURSE IN IMMUNIZATION PRACTICE (CCIP) (July 2013- October 2013)
Name: (In block letters)
Affix a passport size photograph
Father’s/Husband Name: Gender:
Male
Current Affiliation:
Female
Private Practice
State Government Job
Central Government
NGO
Other
If other, please specify……………………………………………………………….
Teaching Affiliation:
Yes
No
if yes:
State Govt
Central Govt
Private
Current Address: • Place
of
work
Street Nearest landmark City
State
Pin code
Phone No. with STD code
• Residence Street Nearest landmark City
State
Pin code
Phone No. with STD code
Preferred Address for Mailing
Place of Work
Mobile Number Preferred Email
Residence Fax Number
number
for
Communication
id:
Date of Birth
D
D
M M
Y
Y
Y
Y
Medical Council Registration No. Date
D
D
M M
Y
Y
Y
Y
(Attach Proof) State CERTIFICATE COURSE IN IMMUNIZATION PRACTICE (CCIP)
Page 1 of 4
Enrollment Form for Participants
Education Academic/ technical/ professional Qualifications Qualification
College/Institution/University
Year of Completion
M.B.B.S MD/DNB MS DM PhD Diploma Other (Attach Separate Sheet, if necessary) Immunization Training Have you received any training on Immunization?
Yes
No
Details: S. No.
Title of Training
Duration (Days)
Organization/ Institution
Experience Total Years of Experience
years (post internship)
Current Designation _______________________________________________________________________________ Current Organization/ Govt./Clinic/Hospital ____________________________________________________ Are you conducting Immunization Clinics/ Sessions/ Camps?
Yes
No
If yes, please specify________________________________________________________________________________
Details of Experience Designation
Page 2 of 4
Organization
From
CERTIFICATE COURSE IN IMMUNIZATION PRACTICE (CCIP)
To
Enrollment Form for Participants
(Attach Separate Sheet, if necessary) Any Additional Information/ Achievements (Publications, Awards, Fellowships, Scholarships, if any): (Attach Separate Sheet, if necessary) ____________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ____________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ____________________________ Do you use internet and check emails regularly?
Yes
No
Possible Reason for Enrolment in CCIP course (please tick) Knowledge enhancement only
Knowledge enhancement for utilization in action Other reason (Specify) ______________________________________________________________________ What are your expectations from this course? (Please attach separate sheet, if required) ____________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ________________________________
Declaration I hereby declare that the above mentioned information, which I have provided, is true to the best of my knowledge. I shall participate in the contact sessions organized once in a month on Sundays and will devote self-reading time for all the modules in the course and participate in assessments, organized by the offering institutions. I understand that by participating in this course, I am enhancing my knowledge and skills related to immunization and completion of said course will not entitle me the status of an Immunization expert. I also understand that this certificate course is not a recognized medical qualification, under section 11(1) of the Indian Medical Council Act, 1956 and the institution offering this course is neither a medical college or a University nor offering the course in accordance with the provisions of the Indian Medical Council Act and university Grants Commission Act.
Name:______________________________________
Signature:______________________________________
Date:_______________________________________
Place:__________________________________________
CERTIFICATE COURSE IN IMMUNIZATION PRACTICE (CCIP)
Page 3 of 4
Enrollment Form for Participants
Check List of attachments with this application form (Please Tick) 1
Passport size color photograph
2
MCI/State Council Registration Certificate
3
MBBS Degree Certificate
Demand Draft for INR 5,000 drawn in favor of “Public Health Foundation of India” payable at
New Delhi
Demand Draft No: ____________________________________ Dated: ____________________________ Name of Bank and Branch ____________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________
Please mail this form along with the required documents to: Program Manager Program Secretariat- CCIP Public Health Foundation of India Plot No. 14, Community Centre, Panchsheel Park, New Delhi- 110016 Email:
[email protected] Phone No.: 011- 41213100, Mobile No.: 09015562467
Page 4 of 4
CERTIFICATE COURSE IN IMMUNIZATION PRACTICE (CCIP)
