Domestic Fellowship form

Eligibility criteria for ICP Fellowship can be found Here

For any queries, please email at api.hdo@gmail.com or call at - (022) 6666 3224.

Please mention NA in case of no information available for any point.

* is required

PDF Form

Basic Info

First Name *
Middle Name
Last Name*
Date of Birth*
API Membership Number*
Date of Joining*
Profile Image*
Only JPG / JPEG / PNG are allowed (Upto 5 MB)
Address Residence *
City*
State*
Pin Code*
Address Office *
City*
State*
Pin Code*

Contact

Mobile*
Email*
Telephone

Degree

Postgraduate degree in Medicine*
Institute*
University*
Year of passing*
Attach Certificates *
Only PDF / JPG / JPEG / PNG are allowed (Upto 5 MB)
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Experience in Medical Profession after Post Graduation in Medicine

Name of Hospital/Clinic/Organisation *
Location *
Number of Beds (if applicable)
Post Held *
Period Served year wise (From) *
Period Served year wise (To) *
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Publications (If number of publications in Journals exceeds 8, publications which can qualify as research papers may be listed under Research work section .)

a. Number of Publications in Indexed National / International Journals*
b. Number of Chapter in Books / monograms*
c. Number of Editorship of National level or State level Book /Monogram/Update Series*
Article Title*
Publisher Name*
Published Year*
Attach Certificates*
Only PDF / JPG / JPEG / PNG are allowed (Upto 5 MB)
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Honours And Awards

(a) Oration in National / State Association Meeting

Title of Oration
Organisation
Year
Attach Proof
Only PDF / JPG / JPEG / PNG are allowed (Upto 5 MB)

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(b) Award National / International / or State level

Title of Award
Organisation
Year
Attach Proof
Only PDF / JPG / JPEG / PNG are allowed (Upto 5 MB)

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Research work

(a) Research sanctioned & funded by Research Agency

Research Title
Agency Department
Research year
Research Proof
Only PDF / JPG / JPEG / PNG are allowed (Upto 5 MB)

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(b) Departmental Research. (To qualify, the findings should be published in National/International Journal) Do not include papers already listed under Publications

Research Title
Agency Department
Research Year
Research Proof
Only PDF / JPG / JPEG / PNG are allowed (Upto 5 MB)

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Contribution to API

Post held in Organisation/Meeting
Name of Organisation/Meeting/CME
National/Zonal/Under API/ICP State level
Year
Attach Proof
Only PDF / JPG / JPEG / PNG are allowed (Upto 5 MB)

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Participation in CME or Scientific Sessions of API or ICP as Faculty

Speaker/Chairperson/Other
Title of Talk / Session
Name of meeting
Year
Attach Proof
Only PDF / JPG / JPEG / PNG are allowed (Upto 5 MB)

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Proposer Name*
Proposer Membership Number*
Proposer Mobile Number*
Proposer Email*
Seconder Name*
Seconder Membership Number*
Seconder Mobile Number*
Seconder Email*

Note The Fellowship form should be proposed and seconded by Founder Fellow / Fellow of ICP only. In case there are more than 3 nominations by any proposer/seconder, the first three nominations in order of receipt in API Office and complete in all respects will be considered for award of Fellowship of ICP and the others rejected for consideration.

The Indian College of Physicians

The Indian College of Physicians is the academic wing of the The Association of Physicians of India, a professional body of consultant physicians formed in 1944. It’s members are physicians with postgraduate qualifications in different specialities. ICP was started in 1986 and its first convocation was held in January 1987.

Links

JAPIICPPRFMembers Directory

Contact Info

Association of Physicians of India
Unit 6 & 7, Ground Floor,Turf Estate, Off Dr. E. Moses Road,Near Mahalaxmi Station (West), Mumbai – 400 011.
Tel : (022) 6666 3224Email : api.hdo@gmail.com
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