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INDIAN COLLEGE OF OBSTETRICIANS & GYNAECOLOGISTS

of

The Federation of Obstetric & Gynaecological Societies of India

6^th Floor, New Building, Cama & Albless Hospital, Mahapalika Marg, Mumbai 400 001.

* Tel : 91 - 22 - 2264 23 08     * Fax : 91 - 22 - 2267 64 05

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Application for International Fellowship

I desire to be an International Fellow of the Indian College of Obstetricians & Gynaecologists.  I hereby apply for the same.  I am paying the Fellowship fee in advance.  If duly elected, I shall abide by all the rules and regulations of the College.  I hereby furnish my bio-data.

Date of Application __________  Date of Receipt ____________                      __________________

                                                                        (By Office)                            Signature of Applicant

Name (in Capital)       _______________                      ________________                    __________________

                                                            (Surname)                                              (First Name)                               (Middle Name)

Experience in India :

Current Position :

Permanent Address   ____________________________________________________________________

                                    ____________________________________________________________________

                                    _____________________________________ Pin Code No.__________________

Telephone Nos.          ________________        _______________          ___________________

                                    (Residence)                    (Office)                                      (Mobile)

Fax No.           _______________________                                Email  :______________________

Date of Birth  __________________

Medical Council Registration Number and date,

mentioning the name of the State Register                      _____________________________

Years of practice in Obstetrics & Gynaecology and / or Research in any aspect of Human Reproduction ________________________________

State / National/ International Conferences Attended: (Use additional Sheet of paper, if required)   

Papers presented as FIRST Author at State / National / International  Congresses

(Use additional Sheet of paper, if required)

Papers Published in any recognized Journal/chapters in textbooks/articles in FOGSI Focus etc. (Use additional Sheet of paper, if required)

Proposed by    :           ________________        _________________      _______________

                                    (Surname)                      (First Name)                       (Middle Name)

Address           :           ____________________________________________________________________

                                    ___________________________________________         Pin Code No.____________

Member of Society :  _________________  Signature of the Proposer _____________

Seconded by   :           ________________        _________________      _______________

                                    (Surname)                      (First Name)                  (Middle Name)

Address           :           ____________________________________________________________________

                                    ___________________________________________         Pin Code No.____________

Member of Society :  _________________ Signature of the Proposer ______________

(May be proposed and seconded by any Indian or Foreign Obst & Gyn Specialist)

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To be filled by the Member Society            (Certificate by the Member Society)

(Not Mandatory But Preferable)

This is to Certify that Dr.____________________________________ is a continuous active Member of the Society for the last ___________ years (Date of joining _________________ ) and holds the qualification mentioned above.

__________________________                                                   _____________________________

Signature of the President                                                     Signature of the Hon.Secretary

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To be filled in by the College Office

Serial No._________                Date when application & Payment received _____________

Amount Rs.______________ by Cash / Cheque /Draft

Receipt No._____________       Date ____________

Date when application is approved by the Governing Council _________________

Remarks         ___________________________________________________________________________

            ___________________________________________________________________________

Date and Place of the Convocation when Fellowship Conferred ____________________________

________________                                _________________                  _____________________

President,FOGSI                                Chairman, ICOG                    Hon.Secretary, ICOG

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The eligibility for the International Fellowship is as follows : ( Kindly attach Certified copies for proof ).

1. Person of Indian Origin with Basic graduation from an Indian University.
2. Holding of MD or equivalent qualification for 3 years or more.
3. Membership of any Obstetric & Gynaecological Society for 5 years or more.
4. Publication of 3 papers in any reputed Journal of Obstetrics & Gynaecology or more.
5. Attendance of 2 State / National / International Congresses or more.
6. Presentation of at least 2 papers at State /National / International Congresses at First Author.
7. Passport size photo.
8. Fellowship payment of US $ 750 (Demand Draft or wire transfer in favour of "F.O.G.S.I.").