to Print Application Form

Dr. Arpita Roy award
For doctors working in rural Bihar & Jharkhand 2015-16
The forms in this document can be completed in the following ways:
Print form, completed by hand and mail
complete form digitally, print and mail
complete form digitally, save and send via email as an attachment
Deadline for materials due in our office: 10 April, 2015
Please type or print all information
Personal Information
Name
Sex
Age
Mailing Address
District
State
Telephone No/ Mobile
Email:
Pin code
Education
Medical college
Year
Address
District
State
Internship
Pin code
Year
Address
District
State
Medical Registration Number
Pin code
Year
Any further Qualification/ Training
Professional Experience
Institution
Year
Designation
Address
District
State
Telephone No/ Mobile
Email:
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Pin code
References
Please list three Professional references
Name
Address
Telephone No/ Mobile
E-mail:
Name
Address
Telephone No/ Mobile
E-mail:
Name
Address
Telephone No/ Mobile
E-mail:
With your application please enclose documents detailing the following:
Your research and publications
Awards and prizes received
Media coverage received
Suggestions and Innovative ideas to reduce
the burden of cancer in rural communities
Your contributions in any of the following areas of cancer management:
Education and Prevention
Early Detection
Treatment
Palliative care
Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge. If I am
selected, I understand that false or misleading information may reject my application.
Signature
Place/Date
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Dr. Arpita Roy award for doctors working in rural
Bihar & Jharkhand 2015-16
The Last Date for applications is 10 April 2015
Eligibility:
The award is open to Medical Graduates – MBBS/ BDS
Selection of Awardees:
The selection will be made by a Selection Committee of renowned
medical professional of international reputation
The award will be announced on 26 May 2015
Travel and hospitality of the Awardees will be borne by Vision Paradise.
You may download the application form & Information booklet
from our website: www.visionparadise.in
Successful applicant will be notified before 15 May, 2015
The application should be addressed to
The Director
Vision Paradise: C-2, 2307 Vasant Kunj, New Delhi 110070,
Phone: +91-11-47640642, 41667975, +919891831317, +919868629263
E-mail: [email protected]
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