Please attach 3 passport size photographs in this box & write your name on the back of each photograph

India

APPLICATION FORM

PLEASE PRINT ALL DETAILS

This form should be completed ONLY by students starting courses at Rila Institute of Health Sciences Delhi and Pune hub. Application forms for other hubs available from www.gpcourses.co

Please return the completed form together with registration fee of £120.00 payable to “Rila” to:

Rila, 73 Newman Street, London W1T 3EJ

Tel: +44(0)207 637 3544 | Fax: +44(0)207 580 7166,

Website: www.gpcourses.co | Email:

Postgraduate Diploma in (tick as required)

Cardiology (Delhi) Family Medicine (Pune)

Your Medical Council Name & Registration Number or FD______

Course Starting Date______

1.  PERSONAL INFORMATION
Title: Mr/Ms/Mrs/Miss/Dr______Male/Female ______
Surname/Family Name Previous surname if changed
______
First Name/s ______Date of birth ______
Home Address Work Address
______
______
______
______
______
Telephone No. ______Telephone No. ______
Email address: ______Email address: ______
2.  DISABILITIES/SPECIAL NEEDS
Please tick the box if you have a physical or sensory disability which might in some way affect your studies on the course or may require special facilities or treatment ÿ
Physical or other Disabilities or medical conditions including any which might necessitate special arrangements or facilities
If you have a disability or special needs please tick the box next to statements below that are most appropriate to you:
ÿ you have dyslexia ÿ you need personal care support
ÿ you are blind/partially sighted ÿ you have mental health difficulties
ÿ you are deaf/hard of hearing ÿ you have an unseen disability eg. diabetes, epilepsy, asthma
ÿ you are a wheel chair user/ ÿ you have a disability or special need not listed.
have mobility difficulties please give details______
______
______
3.  Where did you hear about this course? ______
4. CURRENT AND PREVIOUS WORK EXPERIENCE WITHIN THE LAST FIVE YEARS
Job Title
Nature of Work/Training / Name of Organisation / Full/Part Time / From / To
5. ACADEMIC & PROFESSIONAL QUALIFICATIONS (please list the most recent first). Continue on a
Separate sheet if necessary.
Level / Date / Subject / Place of Study/Awarding Body / Classification
6. If you are a non-native speaker of English or your primary medical degree was not taught in the English medium please give details of your highest English Language qualification (eg IELTS, TOEFL)
Name Date of Award Subject Place of Study Grade or Classification
______
7. ACCESS TO RESOURCES
Will you have regular access to IT facilities including the internet? Yes No
8. Declaration: I confirm that, to the best of my knowledge, the information given in this form is correct. I have read the course details and agree to abide by the conditions set out.
Applicant’s signature: ______Date: ______

EQUAL OPPORTUNITIES POLICY MONITORING

Planning Statistics

The information you give in response to this section is required only for statistical purposes, eg. For monitoring application and admission rates, and for planning future provision in Medical Education. It will be treated in the strictest confidence.

Ethnic Background

Please tick the relevant box

Asian or Asian British Black or Black British Mixed

ÿ Bangladeshi ÿ African ÿ White & Black African
ÿ Indian ÿ Caribbean ÿ White & Asian
ÿ Pakistani ÿ Black Other* ÿ White & Caribbean
ÿ Asian Other* ÿ Mixed Other*

White Other Ethnic Groups

ÿ White British ÿ Chinese
ÿ White Irish ÿ Any other Ethnic Group*
ÿ White Other* *Please Specify ______
(Categories as recommended by the Commission for Racial Equality)
ADMISSION CRITERIA
Students admitted to a Rila Postgraduate Medical programme must be:
·  In possession of an MBBS or equivalent medical degree.
·  For doctors qualified outside the UK a “STATEMENT OF MEDICAL QUALIFICATION” MUST be completed as indicated and returned with the application form
·  For doctors qualified outside UK evidence of a formal English Language qualification or fluency in English MUST be provided. The evidence that is acceptable is detailed under “English Language Requirements” and this MUST accompany your application form.
·  Provide all the following documentation:
-  Completed application form
-  Evidence of your medical qualification (an attested copy of your degree)
-  Referee’s report
-  English language requirements (attested copies of any qualifications required)
-  Include registration fees payable: check on www.rila.in/
-  Provide information for visa purposes

OFFICE USE

Year ______Course ______
Date Received ______
Offer ______Accept ______
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