New SICS Application form.doc - Vision 2020

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New SICS Application form.doc - Vision 2020 Powered By Docstoc
					 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: training@lionsloresho.org


                        Uncompleted Application Forms will be rejected.

				
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