Instrument Maintenance Course for Ophthalmologists

Application Form

Name:

Instructions

i) The Application Process

Your application consists of three parts: this form, the nomination form, and your photograph. You are responsible for completing the application and providing a photograph.

Typed applications are preferred. If handwritten, please write clearly in block letters. To enable us to better meet your needs and expectations, you must answer all of the questions listed.

Please sign and date the declaration. If submitted electronically, your typed name will count as your signature.

A passport sized photograph (as a .jpg) should either be attached to your emailed application or affixed to your printed application.

ii) Question 1-5: Personal Details

Failure to provide a telephone number, fax or e-mail address could cause delays in communicating the status of your application.

All course communication will be sent to the Current Address,while the Permanent Address will be used for future communication.

iii) Question 6: For Non-Indian Participants Only

Provide the correct address of your country’s Indianembassy or consulateso that we may send a formal visa invitation letter to the Indian embassy on your behalf.

iv) The course will be taughtEnglish

v) Submissions and inquiries:

Contact person:Prof N. Manickam

Position:Consultant

Address for Communication:Aravind Eye Hospital
1,Anna Nagar,
Madurai - 625 020Fax: 0452 - 253 0984

Phone:04524356100

Fax:04522530984

E – mail:

1)Personal Details

Title : Mr Ms Dr

Name:

Nick name or familiar name for name badge:

Date of Birth: Sex: Male / Female Nationality: d d m m y y

Current Address Permanent Address

StreetStreet

StateState

CountryCountry

Postal CodePostal Code

PhonePhone

Fax NoFax No

MobileMobile

EmailEmail

List your academic qualifications, starting with the mostrecent degree

Degree / Major / College/University & Location / Duration in Years / Graduation Date
DD MM YY

Language Proficiency:

I hereby declare that I have adequate English listening, speaking, reading and writing proficiency to undertake this course:

List other languages known:

2)Employer Details:

Employer Name:

Position:

Type of Organization: Government /Private /Voluntary Organization / Other

Employer Address

Street

State

Country Postal Code

Phone Fax No

Email Website

3) Professional Experience

Employment Record: Please list positions held during the last 5 years, starting with your present position

Name of the Organisation / Title or Position / Period
From
DD MM YY / To
DD MM YY

4)Fee Payment

a) Self-financed

Method of Payment
Cash / DD / Wire Transfer

b) Sponsored

Sponsor’s Details:

Name of the organisation:

Name of the contact person:

Contact Details:

5) Information for Course Design:

a) Specify the positionor job title of the person to whom you report and the number and positions of the people you supervise.

b) Briefly describeyour current duties and responsibilities.

c) Describe your areas of specialisation, interest and ability that would contribute to classroom discussions.

d) What are some current problems that you face in your organisation relating to your work?

e) Briefly state what you expect to get out of this course and your goals for attending.

f) How did you hear about this course and about Aravind Eye Hospital?

6) For Non-Indian Participants Only

Country

Passport No:

Address of your country’s Indian Embassy or Consulate where you would apply for a visa

Street

State

Country Postal Code

Phone Fax No

E – Mail Website

Declaration: I declare that the information provided in this application and the documentation supporting is correct and complete.

Signature of the Applicant: Date: