Application Form for Internship
1. Name of the candidate
*
(in full)
-Select-
Mr.
Ms.
Mrs.
Dr.
2. Date of Birth
*
[DD/MM/YYYY]
Age
*
Years
3. Sex
*
--Select--
Male
Female
4. Address for Correspondence
*
5. Permanent residential address
*
6. Contact No. Res :
Mobile :
*
7. Email address
*
8. Pursuing Degree/Course
*
Semester
*
9. Date of start [MM/YY]
*
Date of Completion [MM/YY]
*
10. Name of the Institute and its Affliation
*
11. Academic Qualifications [From 10+2] onwards
*
Examination or Degree obtained
Name of School/Board/University
Date of passing
Subject taken
Grade / Percentage of marks
ADD Qualification
12. Achievements [if any]: State-level Medals, Scholarships, Prizes or any other Award, Distincation or Honour won :
13. Other Qualification [if any] :
14. Research Training / Experience [if any]:
15. State exact period of internship requested
*
: From
To
16. Discipline in which internship at NCDIR is sought:
*
Non-Communicable Disease Epidemiology
Medical Statistics
Information Technology
Bioethics
17. Specify learning objectives during internship at NCDIR:
Date
List of enclosures required to be submitted with the Application (Only .pdf file format are allowed)
1. Photo (Size: <20 KB)
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No file selected
2. Certificate of Graduate Degree / Diploma
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No file selected
3. Mark sheet of Postgraduate Degree / Diploma
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No file selected
4. Concept note of work to be taken up during internship (2 pages)
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No file selected
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