WWWORTHOTEERSCOM APPLICATION FOR FRESH RENEWAL OF HONORARY SUBSCRIPTIONS APPLICATION

www.orthoteers.com

APPLICATION FOR FRESH/ RENEWAL OF HONORARY

SUBSCRIPTIONS

Application Ref No (Office Use Only) :

Date of application :

Date of subscription (Office Use Only) :

Correspondence address :

Dr. Deepak.S

Assistant Professor, Orthopaedics

82, 36^th Main, 4^th A Cross,

B.T.M. Lay Out I Phase, I Stage

Bangalore 560 068

Ph – 00919845198488

Email to be sent to both by 01-02-2009

[email protected]

Please complete the form in black ink, using either block capital letters or typescript.

Please read the rules and regulations of ORTHOTEERS before you complete this form.

Personal information

Surname :

First Name:

Address :

Postcode:

Telephone number: Home:

Hospital:

Mobile:

E-Mail :

Institutional information:

Name Of the Institution :

Address :

Post code :

Telephone number: Hospital:

Bleep:

Academic Details

Degree

College

University & Year of graduation

MBBS

M.S / Diploma/ DNB

Professional Registration / Membership

Name of Organization

Registration Number

Expiry Date

Orthopedic Association membership

Name of Association

Registration Number

Type of membership

Supporting Information

Please Opine - Fresh Subscriptions - Why do I want ORTHOTEERS (100 words)

Renewal Subscriptions – Influence of Orthoteers in last year (250 words)

Fresh Subscription

Criteria	Points	Scored	Evidence
Undergraduate studies
First Class marks in any of two clinical subjects	10		Marks card
Outstanding academic awards	10		Certificate
Participation in Intercollegiate Quiz / academic seminars	10		Certificate
Experience in research work / Publications	10		Certificate
Post Graduate Studies
Final year in Post graduation	10
Podium/paper presentations
Local society meetings (for every 3 )	10		Certificate
State level conferences (for every 2)	10		Certificate
Regional Level Conferences (for every 1)	10		Certificate
National level Conferences ( for every 1)	10		Certificate
Publications in journals (for every 1)	10		Certificate
Recognized courses (for every 2)	10		Certificate
Awards in Scientific meetings (for every 1)	10		Certificate
Basic computer knowledge (windows /MS Office)	10		Referee

For free Renewal – (Note- All Activities should be in the concluding year of subscription .This is just an attempt to know the usage of the website and its impact on the academics in the year of subscription)

Criteria	Points	Scored	Evidence
Maintenance of Orthoteers log book	10		Web site
Contribution of articles to Orthoteers (For every 1)	10		Web site
Contribution of images to Orthoteers (for every 20)	10		Web site
Podium/paper presentations
Local society meetings (for every 3 )	10		Certificate
State level conferences (for every 1)	10		Certificate
Regional Level Conferences (for every 1)	10		Certificate
National level Conferences ( for every 1)	10		Certificate
Publications in journals (for every 1)	10		Certificate
Recognized courses (ATLS, AO etc..) (for every 1)	10		Certificate
Awards in Scientific meetings (for every 1)	10		Certificate
Influence of Orthoteers in the last year (250 words)	20	Office use	Office use

Other Relevant academic skills

Referees recommendations:

(Note concerning referees: Referees should be Senior Academic and/or Professional persons who are currently responsible, or have recently been responsible, for supervising you. Close personal friends and family are not acceptable as referees.)

Recommendation

Referees details

Student’s Skills

Yes

Name

Position

Address

Telephone No

Signature

Academic skills

Computer skills

Research works

Presentation skills

Name

Position

Address

Telephone No.

Signature

Academic skills

Computer skills

Research works

Presentation skills

CONSENT

I have read the Guidance Notes for Applicants that accompany my application form and the www.Orthoteers.com website. I confirm that the information that I have provided in this form is correct and complete I understand and accept that if I withhold information or do not comply with the guidelines and policies of ORTHOTEERS may result in withdrawing my subscription. I understand that the final decision of allotting the honorary

subscription lies with ORTHOTEERS.

Signed: Date:

(Sending it through e mail is considered as an acceptance of the above consent)

For Office Use only

Points acquired in total
Any discretionary points
Recommended for subscription	Yes / No

Note:

The last date for submissions of the applications through email is 1^st Mar 09.
The Free subscriptions will be given on the point based criteria.
The supporting documents should reach the correspondence address given by 15^th March 2009.
Subscriptions will be allotted to the applicants on the basis of points scored.
Final allocation of the subscriptions will be entirely at the discretions of ORTHOTEERS (UK) and KOACON organising Committee.
Applicants who have been successful would be intimated through E-mail and the user name and password will be supplied to them.

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