| FETP

FETP Course Admission Registration Form

* Mandatory field

Prefix*

First Name*

Middle Name

Last Name*

Date of Birth*

Gender*

Father's / Mother's Name*

Community

Current Address*

District*

State*

Pincode*

Mobile Number*

Email Id*

Relevant Bachelors/ Undergraduate*

Name of the degree*

Year of Passing*

Institution*

University*

Masters/ Postgraduate/ Fellowships or any other equivalent qualification:

Name of the degree

Year of Passing

Institution

University

Click "Add Degree" for every additional degrees Add Degree

PG Degree	Year of Passing	Institution	University	Delete	Edit	row_id

Current work experience:

Type of Organization*

Type of employment*

Name of the organisation*

Current designation*

Experience in the current position (in years)*

Key responsibilities in your current position*

Office Address*

District*

State*

Pincode*

Past work experience: if any

Designation

Name of the organisation

Experience (in years)

Click "Add Experience" for every experience details Add Experience

Designation	Name of Organisation	Experience (in years)	Edit	Delete	row_id

Computer Skills::

Microsoft Word

Microsoft Excel

Microsoft PowerPoint

Photo*

Upload photo of dimensions (4.5 x 3.5 in cms)

Birth Certificate/ 10th Mark sheet/ 12th Mark sheet*

Undergraduate degree certificate*

Highest Postgraduate degree certificate (if any)

No Objection Certificate

Signature*

Upload photo of dimensions (2.5 x 6 in cms)

Self-declaration:

I hereby declare that the particulars given above and the declaration made therein are true to the best of my knowledge and belief. I understand that if my information is found false (or) incorrect at any stage, my candidature shall be liable to cancellation without notice (or) any compensation in lieu thereof.

I am aware that the selection is not guaranteed for all the applicants.

I am aware that the program is an in-service training program. ICMR-NIE and the Department of Health and Family Welfare and Medical Education, Chhattisgarh has the right to deny admission if the required documents are not submitted on time.

Place

Date

2024-10-18