‘Leadership in Public Health Management’
Application & Registration form (PART TIME & WEEKEND)
(This form will be accepted only on payment of Rs. 1000/- towards processing and registration. See prospectus for the details)
Family Name/Other Name
Sex
Date of Birth (dd/mm/yy)
Please Quote Application Number. (Those candidates who have bought the Prospectus may please quote the number given on the Application Form)
Qualification (please list all certificate, degree and diploma courses completed) (Use one box for each course)
Degree Year of Completion
Current Mailing Address
City
Pin Code
State
Country
Phone
Fax
Email
Register me At
MGIMS,Sevagram
Seth G.S Medical College & KEM Hospital, Mumbai
LTMGH & LTMMC (Sion Hospital)
Register me For
Weekend Course Part Time Course
Registration Fees paid by
Give Draft Details (Number, Bank Name, Payable at, Date of Issue)
Work Experience
(Last 5 years only)
Research Work Experience
(List Key Experience of last 5 years only)
Publications/Papers Published in the last 5 year only
I know MS Office and How to work on computers
Yes No
Please highlight the reasons as to why you propose to enroll for the course (Not more than 200 words. 12 point Times roman,Single spacing)
How did you come to know about the course? (Source of Information)
