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Y R Gaitonde Centre for AIDS
Research and Education
FELLOWSHIP IN HIV MEDICINE

Click here to download the Application in pdf version

1. Applicant's Name^*:

2. Date of Birth^*:

3. Age^*:

4. Gender^*:

Male Female

5. Nationality^*:

6. Address:

a. Permanent Address^*

Door no. & Street:

District/City:

Pin Code:

State:

Country:

b. Address for Communication^*

Same as above

Door no. & Street:

District/City:

Pin Code:

State:

Country:

7. Phone Number ^*(With Code):

Mobile:

Landline:

8. Email^*:

Primary Mail id:

Alternate Mail id:

9. Languages Known ^* (Specify: Excellent, Good, Satisfactory):

Language	Speak	Read	Write
English

10. Educational Qualifications ^*(Chronological Order):
Degree/ Diploma	Institution/College and Location	Year(s) From - To	Field of Study
M.B.B.S		-
PG		-
		-
		-
		-

11. Work Experience (Chronological Order):
Designation	Organisation/ Hospital/Clinic	Year(s) From - To	Govt./NGO/ Hospital/Private	Full Time/ Part-Time
		-
		-
		-
		-
		-
12. Current Employment Status:
Designation	Organisation/ Hospital/Clinic	Year(s) From - To	Govt./NGO/ Hospital/Private	Full Time/ Part-Time
		-
		-
Job Profile/Roles and Responsibilities:

13. Previous Trainings/Workshops/Symposium Attended (Chronological Order):

14. Publications/Contributions (If any):

15. Project Thesis/Doctoral Study (If any):

16. Awards and Honors (If any):

17. Membership Details (Organizations/Academy):
Position Held	Title of Organisation/ Academy/ Committee	Nature of Membership	Year(s) From - To
			-
			-
			-
18. References^*: Complete Details (Name, Designation, Address, Phone, E-mail, etc.)
1
2
19. Prior Experience in HIV/STI : (If any)

20. Future Plans^* :

21. Number of HIV/STD patients seen per month (If any):

HIV

STD

Hospital

Private Clinic

22. How did you come to know about this fellowship?^*

Internet /List Groups		Reference
Newspaper		IMA Meetings
Newsletter		Others
YRG CARE Website
Please Specify (like which newspaper, website, etc.):
Declaration: I hereby confirm that the information submitted in this application form and all supporting documents is complete and true.


^* Fields are Mandatory

YR Gaitonde Centre for AIDS Research and Education, VHS Campus, Rajiv Gandhi Road, Taramani, Chennai 600113 India. T:+91 44 22542929 F:+91 22542939 E:info@yrgcare.org