1
Personal Details :
Name of the candidate
*
(in full)
-Select title-
Mr.
Ms.
Mrs.
Dr.
Date of Birth
*
Age
*
Years
Sex
*
--Select--
Male
Female
Other
Address for Correspondence
*
Permanent Residential Address
*
Contact No. (Res)
Mobile
*
Email Address
*
(This email will be registered for purpose of uploading the application)
2
Course & Institute Details :
Pursuing Degree / Course
*
Semester
*
Date of Start
*
Date of Completion
*
Name of the Institute and its Affiliation
*
3
Academic Qualifications
(from 10+2 onwards) :
*
Examination / Degree Obtained
School / Board / University
Date of Passing
Subject Taken
Grade / % of Marks
Action
+ Add Qualification
4
Achievements & Experience :
Achievements [if any]:
State-level Medals, Scholarships, Prizes or any other Award, Distincation or Honour won :
Other Qualification [if any] :
(if any)
Research Training / Experience [if any]:
(if any)
5
Internship Details :
State exact period of internship requested:
*
From
To
Discipline in which internship at NINE is sought:
*
Non-Communicable Disease Epidemiology
Medical Statistics
Information Technology
Specify learning objectives during internship at NINE:
Date
Signature of the applicant (on final printed copy, if applicable)
6
List of enclosures required to be submitted with the Application :
(upload scanned copies)
1. CV
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2. Marksheets of 10th/12th ; Certificate of Diploma & graduate course; Marksheets of current post-graduate course
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3. Awards and honors
(if any)
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4. . Concept note of work to be taken up during internship
[2 pages]
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Submit Application Form