APPLICATION FOR FRESH/ RENEWAL OF FREE

SUBSCRIPTIONS

Application Ref No(Office Use Only) :
Date of application :
Date of subscription (Office Use Only): / ORTHOTEERS
Orthoteers.com
Bridgewater Hospital120 Princess Road
Manchester
M15 5AT
United Kingdom
Tel: +44 (0)161 227 0027
Contact - /

Please complete the form in black ink, using either block capital letters or typescript.

Please read the rules and regulations of ORTHOTEERS before you complete this form.

Personal information
Surname : / First Name:
Address :
Postcode:
Telephone number:Home: / Hospital:
Mobile: / E-Mail :

Institutional information:

Name Of the Institution :
Address :
Post code :
Telephone number:Hospital: / Bleep:

Academic Details

Degree / College /
University
/ Year of passing / Joining
MBBS
M.S / Diploma/ DNB

Professional Registration / Membership

Name of Organization / Registration Number / Expiry Date

Orthopedic Association membership

Name of Association / Registration Number / Type of membership

Supporting Information

Please Opine - Fresh Subscriptions - Why do I want ORTHOTEERS (100 words)

Renewal Subscriptions – Influence of Orthoteers in last year (250 words)

Fresh Subscription

Criteria / Points / Scored / Evidence
Undergraduate studies
First Class marks in any of two clinical subjects / 10 / Marks card
Outstanding academic awards / 10 / Certificate
Participation in Intercollegiate Quiz / academic seminars / 10 / Certificate
Experience in research work / Publications / 10 / Certificate
Post Graduate Studies
Final year in Post graduation / 10
Podium/paper presentations
  • Local society meetings (for every 3 )
/ 10 / Certificate
  • State level conferences (for every 2)
/ 10 / Certificate
  • Regional Level Conferences (for every 1)
/ 10 / Certificate
  • National level Conferences ( for every 1)
/ 10 / Certificate
  • Publications in journals (for every 1)
/ 10 / Certificate
  • Recognized courses (for every 1)
/ 10 / Certificate
Awards in Scientific meetings (for every 1) / 10 / Certificate
Research / dissertation works / 10 / Referee
Basic computer knowledge (windows /MS Office) / 10 / Referee

For free Renewal– (Note- All Activities should be in the concluding year of subscription )

Criteria / Points / Scored / Evidence
Maintenance of Orthoteers log book / 10 / Web site
Contribution of articles to Orthoteers (For every 1) / 10 / Web site
Contribution of images to Orthoteers (for every 20) / 10 / Web site
Podium/paper presentations
  • Local society meetings (for every 3 )
/ 10 / Certificate
  • State level conferences (for every 1)
/ 10 / Certificate
  • Regional Level Conferences (for every 1)
/ 10 / Certificate
  • National level Conferences ( for every 1)
/ 10 / Certificate
Publications in journals (for every 1) / 10 / Certificate
Recognized courses (ATLS, AO etc..) (for every 1) / 10 / Certificate
Awards in Scientific meetings (for every 1) / 10 / Certificate
Influence of Orthoteers in the last year (250 words) / 20 / Office use / Office
use

Other Relevant academic skills

Referees recommendations:

(Note concerning referees: Referees should be Senior Academic and/or Professional persons who are currently responsible, or have recently been responsible, for supervising you. Close personal friends and family are not acceptable as referees.)

Recommendation

Referees details / Student’s Skills / Yes / No
Name
Position
Address
Email
Telephone No
Signature / Academic skills
Computer skills
Research works
Presentation skills
Name
Position
Address
Email
Telephone No.
Signature / Academic skills
Computer skills
Research works
Presentation skills

CONSENT

I have read the Guidance Notes for Applicants that accompany my application form and the website. I confirm that the information that I have provided in this form is correct and complete I understand and accept that if I withhold information or do not comply with the guidelines and policies of ORTHOTEERS may result in withdrawing my subscription. I understand that the final decision of allotting the honorary Subscription lies with ORTHOTEERS.COM.

Signed: Date:

(Sending it through e-mail is considered as an acceptance of the above consent)

For Office Use only (Orthoteers.com)

Points acquired in total
Any discretionary points
Recommended for subscription / Yes / No

Note:

  1. The Free subscriptions will be given on the point-based criteria.
  2. The application form should be submitted to OASISCON Conference committee
  3. The rights of allocation of membership lies with Orthoteers.com
  4. Applicants who have been successful would be intimated through E-mail and the user name and password will be supplied to them.

(For office use of OASISCON committee)

Recommendation for Free merit based applications

Name of the Recommending Association / Orthopaedic Association of South Indian States
Contact information / Email –
Phone
Fax -

Details of the applicant

Surname : / First Name:
Name Of the Institution :
Year of passing MBBS exams :
Names of Referees of applicant : 1.
2.

Recommendation of the association:

The association has screened the application form and supporting documents submitted by the applicant and hereby recommend / do not recommend for merit based free subscriptions from Orthoteers.com.

Authorised signatory

(President/ Secretary)