APPLICATION FORM

Developing and Sustaining India's Capacity for Pre-Clinical Drug Discovery

" Train the Educator" course for educators/trainers who provide education, training and continuing
professional development in laboratory animal sciences for early career researchers
8th -12th July 2019 , ICMR-National Institute of Nutrition, Hyderabad

Please read the prospectus carefully before filling up this form
LAST DATE TO SUBMIT THE FILLED IN APPLICATION FORM 30.04.2019
Part - I General Information Registration ID : PCTNIN5558I
1. Name of the Organization Organization type Governament Private
2. Institution or Company or Industry
3. Name of the Ministry affiliated to Organization

4. Specify the category:

categories

Pharmacy

Clinical

Food

Veterinary

Industry

Others

Phg

N-phg

Al

Ayr

Uni/Sd/Hom

Nutr

Diet

Phg

N-phg

Pre-Cl

Cl

Zlg

PG

Ac

Phg-Pharmacology, N-Non, Al-Allopathy, Ayr-Ayurvedic, Uni-unani, Sd-Siddha,Hom-Homeopathy, Nutr-Nutrition, Diet-dietician, Pre-Cl-Pre- clinical, Cl-Clinical, Zlg-Zoology, PG-Post Graduate in Science/Technology, Ac- Academic


5. Name of the Candidate (as per records)
6. Name of the Father/Husband/Guardian/any Legal Representative
7. Nationality
8. Official Address
E-Mail
Mobile
Office Number

PART - II (PERSONNEL INFORMATION)
1. Date Of Birth    

2. Age
3. Gender Male Female Others
Educational Qualification

(Indicate your answer by selecting Mark, Don't select whichever is not applicable)

a) Medical Graduate  
b) Ph .D  
c) Medical Post graduate  
d) M. Pharmacy/Pharm D  
e) M.Sc  
Others  

Educational Details :

Name of the examination/ Degree obtained University Month and Year of Passing Percentage (%)
Graduate
Post Graduate
Doctorate
Any Others

PART - III (PROFESSIONAL INFORMATION)

1. Particulars of experience for 5 years involved in non clinical (animal/in vitro experimentation) or engaged in teaching institutes having animal house facility. (Has to be certified by competent authority)


Experience Field

Duration

Details of Experience

From

To


2. Have you attended any workshop in drug evaluation (safety/efficacy) in last 3 years:
Duration of the workshop must be minimum 5 days and above.

S. No

Title of the Workshop

Month/Year

Organization name

1.

2.

3.

4.

5.


3. At present are you in drug discovery program ? Yes /No

4. Do you have other staff and students working in the organization in drug discovery Yes/No


5. Do you have a facility to train the junior scientist and students Yes/No
6. Do you have any experience in pre clinical studies: Yes/No


6.4 Are you a member of any institutional Animal Ethics Committee (IAEC): Yes/No


6.5 Do you have experience in teaching/research training in experimental animals Yes/No


6.6. Do you have the registered animal facility: Yes/No


6.7. Why do you wish to attend the workshop & what you hope to get out of it (500 words maximum: Enclose Copy)


DECLARATION

I agree and hereby declare that all statements made in the application are true, complete and correct to the best of my knowledge and belief. I understand that the information furnished in the application form if found incorrect or I do not satisfy the eligibility criteria, my application is liable to be rejected/ cancelled / terminated, without assigning any reasons thereof.

I Agree

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