Management Training and Systems Development for Hospital Administrators and Managers

April 05 – May 02, 2018

Application Form

Applicant’s Name:______

Instructions

A]The Application Process

  1. Your application process consists of 3 parts: Application Form, Nomination Form, and your Photograph. You are responsible for filling the application and providing a photograph, while your direct supervisor or financial sponsor (if applicable) must fill in the short nomination form on your behalf. The nomination form should be sent together with this applicationform. Your application will be reviewed once we have received all of the documents.
  2. Application should be filled in block letters only. Typed applications are preferred (BOLD & UNDERLINED). If handwritten, please write clearly with BLACK BALL POINT PEN. To enable us to meet your needs and expectations, request youtofill in all the details provided in the form.
  3. The declaration should be signed with the date mentioned. If submitted electronically, your typed name will be considered as your signature.
  4. A passport sized recent photograph should be attached to your emailed application (strictly.jpg format) or affixed to your printed application.

B] Question 1: Personal Details

  1. Failure to provide a ContactNumber, Fax or Email-id could cause delays in communicating the status of your application.
  2. All course communication will be sent to the Current Address, while the Permanent Address will be used for future communication.

C] Question 7: For Non-Indian Participants Only

After the receipt of your application form we will send a formal Visa invitation letter to your country’s Indian Embassy orConsulate. Visa processing takes time, so we request you to apply well in advance.

D]Coursecommunication languagewill be inEnglish.

E]Submissions and Enquiries:

Contact person:Mr.B. Udayakumar

Position:Faculty Associate

Address for Communication:Lions Aravind Institute of Community Ophthalmology
72, K.K. Salai, Gandhi Nagar,
Madurai - 625 020, Tamil Nadu, India.Fax: 0452 - 253 0984

Phone:0452 - 4356500

Fax:0452 - 2530984

E – mail:

1)Personal Details:

Title :Mr. Ms. Dr.

Applicant Name: ______

Date of Birth: ______(dd/mm/yy)Nationality: ______

Sex: Male Female

Phone No:______Mobile No.:______

Fax No.:______Email-id: ______

Current Address:______

State: ______Country: ______

Postal code: ______

Permanent Address:______

______

State: ______Country: ______

Postal code: ______

List your academic qualifications, starting with the most recent degree

Degree / Major / College/University & Location / Duration / Graduation Date
(dd/mm/yy)

Additional courses and programmes attended

Course Description / Institute & Location / Duration / 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 (Please mention YES / NO in the appropriate boxes):

Languages / Read / Speak / Write

Have you attended any other education programmes at Aravind Eye Care System?

Course Attended / Period
From
(dd/mm/yy) / To
(dd/mm/yy)

2) Employer Details:

Title :Mr. Ms. Dr.

Employer Name:

Designation:

Organization Name:

Type of Organization: Government ______Private______

Voluntary Organization______Other ______

Date of Birth: ______(dd/mm/yy)

Sex: Male Female

Nationality: ______

Phone No:______Mobile No:______

Fax No.:______Email-id: ______

Address:______

______

State: ______

Country: ______

Postal code: ______

Website:______

3) Professional Experience

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

Name of the organization / Designation / Period
From
(dd/mm/yy) / To
(dd/mm/yy)

4)Fee Payment

Mode of Payment
Cash / DD / Wire Transfer

a) Self-financed

b) Sponsored

5) Nominating Information:

If you are financially sponsored, please list the sponsoring organisation below. If you are self-funded or funded by your hospital, please list the contact information for your supervisor. This person is expected to complete the Nomination Form on your behalf.

Name of the organisation: ______

Name of the contact person: ______

Designation: ______

Sex: Male Female

Nationality: ______

Phone No: ______Mobile No: ______

Fax No :______Email-id: ______

Address: ______

______

State: ______Country: ______

Postal code: ______

Website: ______

6) Information for Course Design:

a) Specify the designation of your reporting authority and also mention the number of people you supervise?

b) Briefly describe your current duties and responsibilities.

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

d) What are the obstacles that you face in your organisation relating to your work?

e) Briefly state what is your expected outcome from this course?

f) From which source you learnt about this course and LAICO?

7) For Non-Indian Participants Only

Country:______

Passport No: ______

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

Address:______

______

State: ______Country: ______

Postal code: ______

Phone No:______Fax No:______

Email-id:______

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

Signature of the ApplicantDate:

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