ISN – ANIO Clinical Nephropathology Certificate Program
Registration Form
** Registration Deadline: October 15, 2012**
(Please print you details clearly in capital letters)
LAST NAME _____________________________ MIDDLE ___________________ FIRST NAME ____________________________________
Year of Birth_______________________ Country of Birth _______________________Country of Citizenship ________________________
ADDRESS: Street and number: ______________________________________________________________________________________
City ___________________________ State___________________ Postal Code ______________Country ___________________________
Phone ___________________________ Mobile _________________________Email ___________________________________________
Degree _____________Professional School attended: ____________________________________________________________________
Year of Graduation: _____________
Current Organization Affiliation: ________________________________________________________ Country_______________________
Current Professional Position: ________________________________________________________________________________________
Registration Prerequisites Checklist† | Please include the following documents with your registration form:
Your resume, stating your educational background, degrees, diplomas, certificates, professional training (no more than three pages).
* Candidate must hold an MD, DNB, DM or PhD degree.
A short paragraph stating why you are interested in ISN-ANIO Clinical Nephropathology Certificate Program (CNC) (no more than one
page).
Letter of verification / recommendation from the Department Head or Immediate supervisor.
Course Fee: $ 150 (USD)
[Please note: Tuition fee is waived for Trainees in MD, DNB, DM or PhD]
PAYMENT METHOD (for non – trainees/ faculty/ attending physicians):
We encourage the course fee to be paid by check: All checks payable to “ISN”
Kindly bring the check for $ 150 USD to the AIIMS – Brigham Nephrology CME venue and present it at the registration desk.
Cash payment is not accepted.
I certify that all of the information contained in this form is true and complete to the best of my knowledge:
Registrant’s Signature: ______________________________________________________Date: __________________________________
GENERAL INFORMATION
REGISTRATION INFORMATION
The registration form must be completed and returned by the registration deadline to ISN-ANIO Clinical Nephropathology Certificate
Program (CNC)l – Dr. Ajay K. Singh, MD, 1620 Tremont Street, 3rd floor, Renal Division, Boston, MA 02120, USA or faxed to +1-617-5257818.
The registration form along with the supporting documents mentioned in the pre requisite checklist † can also be sent by email to
kkaraisubramanian@partners.org
Telephone registration is also accepted by calling +1-617-525-7814 or +1-857-615-4656 [Monday - Friday, 10 AM to 4 PM (EST)]
Upon receipt of your registration form an email confirmation will be sent to you. Be sure to include an email address that you check
frequently. Please answer all questions thoroughly and provide all requested documents—only completed registrations will be accepted.
All selected members/candidates are responsible for their own transportation and lodging during the course.
INQUIRIES
By phone +1-617-525-7814 or +1-857-615-4656 Monday - Friday, 10 AM to 4 PM (EST) or by email at kkaraisubramanian@partners.org
NOTIFICATION OF ADMITTANCE
We acknowledge receipt of all registrations and maintain all registration information in strict confidentiality. Qualified registrants are
admitted on a rolling, space-available basis. Registrants will be notified within one day of receipt of registration regarding program
admittance.
CONFERENCE LOCATION AND DATES
Venue: Ramalingaswamy Board Room, All India Institute of Medical Sciences (AIIMS), New Delhi
Dates: 19th October – 21st October, 2012 (Friday to Sunday)