Application Form

Have you received any IADVL scholarship before?

Yes
No

1 Login

2 Personal Details

First Name *

Last Name *

Date of Birth *

Attach Proof of Date of Birth ( pdf / Image ) *

Age in completed years (on 30-04- 2017) *

Gender *

Address *

Country *

State *

City *

Pincode *

Email Id *

Mobile Number *

IADVL Membership Number *

Years of Membership *

Status *

3 ACADEMIC

Year of passing MBBS *

Institution *

Postgraduate qualification (MD/DDVL/DD/DNB) Year of passing Institution

Post-qualification experience *

Present position *

4 CONFERENCE Details Evaluation weightage - 25%

Conference registration number *

Attach Registration Receipt ( pdf / Image ) *

Title of presentation *

Attach letter of acceptance of presentation ( pdf / Image ) *

Abstract/Synopsis of presentation *

Attach abstract/synopsis ( pdf / Image ) *

5 Presentation in Conferences Evaluation weightage - 25%

Presentations at conferences in the last three years (only presentations at national , international, zonal or state level conferences will be considered)

*Mention Top 10

Type of presentation Title of paper Name and venue of conference Year of conference

6 Publication - Indexed Journals Evaluation weightage - 15%

Publications in the last three years (Mention top 10)

*In peer reviewed indexed journals only; weightage will be given to the first two authors/corresponding author

Type of article Title of paper Name of the journal Year,Vol,Page URL

7 Publication - Books Evaluation weightage - 10%

Chapters/Editors in books in the last 3 years (first two authors only)

Name of chapter (author/Editor) Title of book Publisher Year of print

8 AWARDS Evaluation weightage - 10%

Awards in the last 3 years (State/ Zonal/ National/ International)

Name of award Awarding organization Year of award

9 Participation in IADVL activities Evaluation weightage - 15%

Participation in IADVL Activities / utility to IADVL Members or parent department

Type of participation Name and venue of conference/CME/Workshop/health camp/IADVL Day Year and Month

Brief about 'utility' to IADVL members / Any other relevant information not mentioned above

10 Declaration

Declaration

I have not received or am not going to be receiving funding from any other agency (e.g. the conference organizers, state branches, government, ICMR, pharmaceutical companies, and my institution) for attending this conference.

I will submit a brief report about the conference, my experience and how it benefitted me to the IADVL after the conference.

As an IADVL member can avail only one IADVL scholarship each for national and international conferences in his/her lifetime, I declare that I have not availed an IADVL scholarship for any national/international (strike out as required) conference in the past.

I will abide by the decision of the judges.

All statements made above by me are true. If any are found false, I abide by the rules of the IADVL to take appropriate action which may include refund of the scholarship amount and disqualification from future grants/scholarships/awards.

Name :

Date : 24 Oct 2017

Place :