Post-doctoral international fellowships in Dermatopathology

Correspondence Address:

Application Form

(Use a separate sheet where necessary)

I. Personal details

1. Name
2. Date of birth
3. Age in completed years (on 31-3-2015)
4. Status (Resident/Faculty in medical college/Independent practicing consultant)
5. IADVL membership number & years of membership
6. Mobile number
7. Corresponding address
8. Email address

II. Academic

1. Year of passing MBBS
2. Institution
3. Postgraduate qualification (MD/DDVL/DD/DNB)
4. Year of passing
5. Institution
6. Post-qualification experience
7. Present position
8. Presentations at national/international/zonal/state level conferences in the last three years (Mention the type of presentation, i.e. Oral/Poster/Award paper) (If necessary, attach a separate sheet)
9. Publications in peer reviewed indexed journals in the last three years (weightage will be given to the first two authors/corresponding author) (If necessary, attach a separate sheet)
10. Projects undertaken (other than thesis)
11. Chapters/editors in books (first two authors only) (Give details)
12. Awards (state/zonal/national/international) (Give details)
13. Any special exposure or previous training in dermatopathology

III. Others

1. Participation in IADVL activities (e.g. organizing IADVL days, health camps, etc.) (Please enclose the necessary proof)
2. Contribution to other IADVL members/parent department/patients

IV. Add a separate note on:

1. Any other information explaining why you want this fellowship and any information not mentioned above
2. Your previous experience or training or any other activity to show your interest in dermatopathology
3. Why you are interested in dermatopathology
4. How you wish to take your interest further in the subject of dermatopathology for the benefit of the community and IADVL members after completion of your training.

Declaration

1. I have not received any dermatopathology fellowship by IADVL in the past.
2. I will submit a brief report about the fellowship soon after the completion.
3. I possess a passport and will be willing to travel abroad.
4. I will be able to obtain leave from my job (if employed)
5. All statements made above by me are true. If any of the above are found false, I abide by the rules of IADVL to take appropriate action (which may include refund of scholarship amount/disqualification from future grants/scholarships/awards).

Signature

Name

Date