Working for continuing education & training for clinicians, scientists and community

Section 1: Personal Details

Category 1 (without qualifying examination)Category 2 (with qualifying examination)Either

YesNo

Section 2: Expertise Areas/Disciplines

Section 3:

Academic Record

Professional Experience (Last 3 years)

Section 4:

Talks/Presentations/Posters

Section 5:

Memberships (Professional/Scientific/Medical Organizations)

Awards/ Achievements/Honors

Section 6: PCPM Support Statement

Section 7: Declaration & Check List

I have attached CV along with two professional referees details with this Form.
I confirm that information provided in the form and in my CV are accurate.

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