Indian College of Physicians Format for Submission of Bio – Data of The Nominee for Consideration for Award of Fellowship of Indian College of Physicians. 1. Name in Full (Surname First) (in Block Letters): Upload your latest photograph 2. A. P. I. Membership No. and date of joining: 3. Date of Birth: Address Residence: Address Office: 4. Tel.: Mobile: Email: 5. Postgraduate degree in Medicine Year of passing Institute University Other Professional Qualifications Year Speciality / Subjects University a. b. Certificates Attached: 6. Experience in Medical Profession after Postgraduation in Medicine - Name of Hospital / Clinic / Organisation & Location Number of Beds (if applicable) Period Served year wise (From-To) 1. 2. 3. 4. 5. 7. Publications: List below. (If number of publications in Journals exceeds 8, publications which can qualify as research papers may be listed under Research section 9.) a) Number of Publications in Indexed National / International Journals 1. b) Number of Chapter in Books / monograms – c) Editorship of National level or State level: Book /Monogram/Update Series 8. Honours And Awards (list below with photocopy of proof) (a) Oration in National / State Association Meeting Title of Oration Organisation Year 8. (b) Award National / International / or State level Title of Award Organisation Year 9. Research work (list below) (a) Research sanctioned & funded by Research Agency Attach Letter of sanction (b) Departmental Research. (To qualify, the findings should be published in National/International Journal) Do not include papers already listed under Publications Attach title page / Abstract 10. Contribution to API (list below and attach proof) Post held in Organisation / Meeting: Name of Organisation / Meeting / CME National / Zonal / Under API/ICP State level Year 11. Participation in CME or Scientific Sessions of API or ICP as Faculty Speaker/Chairperson/Other Title of Talk / Session Name of Meeting Year 12. Social welfare / Community service. (Include under the headings given below, with documentary evidence) (a) Emergency services during National calamities (Quakes/ Floods/Cyclones, etc) (b) Public education Programme (Radio), TV talk/ writing in news papers . (c) Service in Rural Areas Service Evidence Indian College of Physicians Citation Please share the details of two proposers for recommendation: Proposer 1: Proposer 2: Name: Name: Membership No.: Membership No.: Email: Email: Mobile No.: Mobile No.: Note:- Once you submit the form – emails will sent to both the proposer for their acceptance or rejection for recommendation.
