17th to 20th January 2019
Clarkes Exotica convention
Resort & Spa
First Name *
Last Name *
Date of Birth *
Attach Proof of Date of Birth ( pdf / Image ) *
Age in completed years (on 30-04- 2018) *
Email Id *
Mobile Number *
IADVL Membership Number *
Years of Membership *
Year of passing MBBS *
Post-qualification experience *
Present position *
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 ) *
Presentations at conferences in the last three years (only presentations at national ,
international, zonal or state level conferences will be considered)
*Mention Top 10
Publications in the last three years (Mention top 10)
*In peer reviewed indexed journals only; weightage will be given to the first two
Chapters/Editors in books in the last 3 years (first two authors only)
Awards in the last 3 years (State/ Zonal/ National/ International)
Participation in IADVL Activities / utility to IADVL Members or parent department
Brief about 'utility' to IADVL members / Any other relevant information not mentioned above
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 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.
Date : 20 Aug 2019
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IADVL Academy Convenor
Thank you for your interest! Only 1 National and 1 International scholarship can be availed in your lifetime.