Observership Form – Spine Society Delhi Chapter

Your Recent Photograph *

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Your Family Name *

Your Name *

Date of Birth *

Nationality *

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Your Marital Status *

Street Address *

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Telephone No. *

Your Email Address *

Place of Present Employment / Name of University / Hospital:

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Telephone No. *

Present Position *

Name of H.O.D *

Medical School (MBBS) Name *

Street Address *

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Date & Year of Graduation *

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Post Graduate Education *

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Orthopaedic / Neurosurgery *

MS(Ortho)/DNB(Ortho)/Mch(Neurosurgery *

Date & Year of Post-Graduation *

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Details about Subspeciality Training in Spine (Trauma, Deformities, Degenerative, Cervical) *

When *

Duration *

Interest in Research *YesNo

In which Areas *

Publications *YesNo

What do you expect from this Observership? *

Conferences Attended *

Which DSS members do you personally know? *

Please explain your association with them *

Other References *

Additional Remarks *

Preferred Centers of Observership *

Preferred Time of Observership (4 Weeks) *

I have read the enclosed Instruction form and accept hereby all conditions *I accept

Date & Place *

SPINE OBSERVERSHIP APPLICATION FORM

Spine Society Delhi Chapter