Department Of Pediatrics, KEM Hospital, Rasta Peth, Pune (411011)
APPLICATION FORM FOR NON-REGISTERED RESIDENDS IN PEDIATRICS
NAME:___________________________________________________________
DATE OF BIRTH:_______________ AGE:_____________________________
Address for all correspondence: ____________________________________________
___________________________________________________________________
City:________________________ State:_______________ZIP:______________
Tel:( area code
) ________________________email:_____________________
Qualifications and year of passing:
1.___________________________________________________________________
2. ___________________________________________________________________
3.___________________________________________________________________
4.____________________________________________________________________
Experience: (Residency training, work experience etc. with dates)
1)__________________________________________________________________
2)__________________________________________________________________
Purpose of doing this nonregistered residency
Wish to continue as a registered candidate in KEM if selected / any other (please
specify)_______________________________________________________________
Please read the following carefully:
1)
2)
Free accommodation and stipend will be provided to the candidates as per the rules of the hospital and availability of space / funds
Certificates, reference letters may be submitted only at the time of interviews.
This form is to be mailed to: Dr. Pandit AN, Director, Department of Pediatrics, KEM Hospital, PUNE (email:kemhrc@vsnl.net, OR
postal address Dr Anand Pandit, Rasta Peth, KEM Hospital, PUNE 411 011 )