ANATOMY SOCIETY OF INDIA

NOMINATION FOR THE

FELLOWSHIP OF THE SOCIETY

Instruction to the proposer

  1. A candidate for Fellowship shall be proposed and recommended by two Fellows in good standing, one of whom shall undertake the responsibility of acting as proposer and the other one as seconder respectively. While support of more Fellows is optional.
  1. The original nomination form should be accompanied by the following material not bound:

a)Five (5) copies of a two-page summary of the scientific contributions.

b)Five (5) copies of the nominee’s Curriculum Vitae including the list of publications.

c)Five (5)copies of Reprints of 3 to 5 most important (Pubmed indexed) papers.

d)Five (5) copies of statement (point-wise) on contributions to the Anatomical Society of India and Medical Education.

  1. One set of reprints of all publications of the nominee.
  1. The last date for receiving the nominations in the secretariat of ASI is 31 May, every year.

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ANATOMICAL SOCIETY OF INDIA

NOMINATION FORM

We the Fellows of the Anatomical Society of India would like to propose:

Name: ______

Father’s Name:______

Husband’s Name: ______

Date of Birth: ______

Position:______

Address: ______

______

for nomination to the Fellowship of the ASI. We append a statement of the nominee’s claims for nomination and certify that in our opinion he/she is fully qualified for that distinction. We also certify that the nominee has been informed of the obligations* attached to the Fellowship of the Society and is agreeable, if nominated, to abide by them.

Proposer (Fellowship No…………....…)Seconder (Fellowship No……………...)

Signature: ______Signature: ______

Name

(Block letters): ______Name: ______

Date: ______Date: ______

Station: ______Station: ______

Name and Signature of Supporting Fellows

Name : ______Signature: ______

Name: ______Signature: ______

Name : ______Signature: ______

Name : ______Signature: ______

Statement by the proposer setting out the merits of the candidate or contributions to knowledge and ASI made by the nominee proposed for the fellowship (NOT TO EXCEED 100 WORDS)

______

Areas of specialization:

(mention three)

  1. ______
  1. ______
  1. ______

Nomination tobe considered

by the Selection committee for :FELLOWSHIP OF ASI, for the year…………………

Members of Selection committee

Presidentof ASI

Gen. Secretary of ASI

Five subjects experts:above the age of 50th years who shall be Fellows of the ASI, one each from the 5 zones.

SUBJECTS

(as in Schedule of SUBJECT appended to the Constitution, Rules and Regulations of the ASI)

(a)Gross Anatomy, Applied Human Anatomy, Anthropology and Primatology.

(b)Neurobiology, Neuroendocrinology and Neurophysiology.

(c)Endocrinology, Reproductive Biology and Fertility Control.

(d)Microcirculation, Biomechanics and Electromyography.

(e)Histology, Hematology, Tissue culture, Immunochemistry, Histochemistry, Cytogenesis and Ultra structural Anatomy.

(f)Embryology, Genetics, Developmental Anatomy and Teratology.

(g)Research Technology, Imaging Science, Radio autography, Fluorescence & Electron Microscopy, Micro spectroscopy and X-ray diffraction.

(h)Eugenics, Race betterment, Human Biology and Medical education.

(i)Any other subject related to biology, fundamental or applied.

Obligations*

  1. Abide by the rules & regulationsframed for the Fellows of ASI.
  2. Will attend all the conferences of ASI unlesson health grounds, which should be informed in writing to the General Secretary of ASI well before the conference.
  3. Should continue to be engaged in research activities and guiding the research work.
  4. If the ASI do desires that your services may be required for the furthering the cause of ASI you would not only accept it but will carry out to the best of your abilities.
  5. That you will not engage in any such activities which may harm the interest of the society.

BIOGRAPHICAL INFORMATION OF THE NOMINEE

(to be filled by the nominee)

Name (expand initials)______

Father’s Name: ______

Husband’s Name:______

Present position______

Date of Birth______

Address______

______

______

Membership of Anatomical Society:Life Member Since ………………

Phone: Off. ______Res. ______

Fax ______Email______

Mobile ______

Academic qualifications: (including UG / PG Degree, PG Diploma, PhD, DSc, Postdoctoral

certificate / fellowships etc.

YearQualificationsUniversity / Institution

______

______

______

______

Positions held (Teaching / Consultant / Research / Administrative etc.in chronological order)

Year (s) Positions heldUniversity / Institution / Others

______

______

______

______

______

______

Awards and Honours

______

______

______

______

______

______

______

Membership / Fellowship of other Societies/Academic Bodies

______

______

______

______

______

Contributions to the Anatomical Society of India:

Contributions to the Medical Education:

PUBLICATIONS:

  1. Books / Monographs / Memoirs / Atlas etc.
  1. Chapter(s) in Books etc.
  1. Research publications.

(i)As First Author.

(ii)As Contributing author.

  1. Review Articles.
  1. Letters to the Editor.

List of the five most important research papers published by the nominee:

Please give: 1) Title of the paper.

2) Names of all authors in the same sequence (as it appears in the papers).

3) Full journal reference.

  1. ______

______

______

______

  1. ______

______

______

______

  1. ______

______

______

______

  1. ______

______

______

______

  1. ______

______

______

______

Any other significant informationto strengthen your nomination.

Dated:……………Signature

Name

Note: In each column / sub-column the space can be expanded, if required.