Lions Medical Training Centre, Kenya ( SHORT TERM COURSE ON SMALL INCISION CATARACT SURGERY (SICS) Name: Office Use : Selected / Not Selected Period : From: To : For International Candidates: KMPDB applied: Yes: No: KMPDB approval: Yes: No: Remarks : Signature Please affix your recent passport photograph here APPLICATION FOR SHORT TERM TRAINING IN SICS Name (Capital Letters) : Present Address: Permanent Address: City: City: : Pin Code: Pin Code: : District: District: : State: State: : Country: Country: : E-mail: Web Site: : Official phone no : Code : Number : Fax No : Residential phone no: Code : Number : Mobile : Fax No : Date of Birth: Age: Sex : Male Female Nationality : Qualification No. Examination Passed Degree Institution Year of passing 1. Basic Degree e.g. MBchB Post Graduate Degree 2. (e.g. M. Med (Ophthalmology) 3 Any other qualifications Present Employment Institution: Designation: Organization Type: Private: Govt.: NGO: Nature of work & responsibilities: Work experience (Past) S.No Organization From To Designation 1. 2. 3. 4 Languages Known: Tick in the relevant column, if you have a working knowledge No. Language Speak Read Write 1. 2. Contact Information Name, address & designation of 2 persons not related to you, whom we can contact for reference 1. Email: 2. Email: Other Training Programme Attended Have you completed Short Term ECCE Training? Yes No If yes, which year did you complete ECCE Training? Month: __________ Year:_________ IOL Training at: ______________________ Surgical Experience No. of ECCE: No. of ECCE with IOL Are you confident with Operating Microscope? Yes No No of SICS: Which microscope are you currently using? Preferred month of Training: Month: __________________ Year: ___________________ For Sponsor candidates only Sponsoring Organization Name: Address: City : Pin code: District: State : Country: Fax No: Email : Web Site : Phone No: Financial Support: (please tick) Course Fee : Accommodation : Food : For International Candidates only Country: ___________________________________ Passport Number: ____________________________ Address of Embassy/Consulate for Visa: ___________________________________________________________________________ ___________________________________________________________________________ Tel: (office)__________________ Fax:________________ Email: _______________ Declaration I hereby declare that all the information given in this form is true and accurate. Date : _______________________ Place: _______________________ Signature Certificate to be attached with the Completed application form (Note: If certificates are not attached, the application will not be considered) 1. Basic Degree Certificate 2. Post Graduate Degree Certificate 3. ECCE / IOL Short-term training certificate 4. Recognition as an Ophthalmologist Certificate Please send the filled in form via e-mail / fax / post to the address below: Training Coordinator Lions Medical Training Centre, Kenya P. O Box 66576-00800 NAIROBI Tel: +254 020 4183239 / 4108401 / 41840626/ ; Fax: +254 020 418 1083 Mobile: +254 728 970 601/ +254 733 619 191 E-mail: firstname.lastname@example.org Uncompleted Application Forms will be rejected.