PROFORMA
(To be filled by the nominee for award of imaams fellowship)

1. Name: Dr ……………………………………………………………………………………
2. Designation: ………………………………………………………………………………
3. Date of Birth: ……………………………………………………………………………
4. Qualifications: ……………………………………………………………………………
   Name of College                 University               Year
   
   i)
   
   ii)
   
   iii)


5. Institutions attached: …………………………………………………………………
6. Membership and Fellowship of the various Scientific Societies (kindly attached photocopy of the each membership / Fellowship certificate)


7. I.M.A. Activities
   i) Office bearers of the Local Branch IMA/State/Sub-Faculty, IMACGP.
   ii) Office bearers of the State.
   iii) Office bearers of the Headquarters
   iv) Office bearers of the Branch Chapter, IMAAMS.
   v) Office bearers of the State Chapter, IMAAMS.
8. Participation in the Academic Programmes in the IMA:                         Year
   i) Attended the Conference organised by Local Branch/IMACGP and State Chapter of academy
   ii) Delivered lectures in the Local Branch/IMACGP and State Chapter academy
   iii) National Conference attended:
9. Awards received (copy of certificates)
                             Name of Award
   i)
   ii)
   iii)
10. Social Service rendered
    Name of                   Date             Certificate/Award
    Organisation         when held       (if SO attach copies)
    i)
    ii)
    iii)
11. Publication (No. of Publication)
    
    
    
    

(Kindly mention in the details your publications as per bibliography given in the Annals of IMA Academy of Medical Specialities)

……………………………………

Signature

Dr. _______________________________

Please click here for download Proforma Form

PROFORMA-NOMINATION FOR FELLOWSHIP
IMA ACADEMY OF MEDICAL SPECIALITIES

Please click here to Read   for download Application Form