Page 25 - Prospectus of Fellowship in Minimal Access Surgery

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Application For Laparoscopy Training

FELLOWSHIP IN MINIMAL ACCESS SURGERY (F.MAS)

WORLD LAPAROSCOPY HOSPITAL

INTERNATIONALLY RECOGNISED BY WORLD ASSOCIATION OF LAPAROSCOPIC SURGEONS (WALS),
THE SOCIETY OF AMERICAN GASTROINTESTINAL ENDOSCOPIC SURGEONS (SAGES)
AND TGO UNIVERSITY, NEW DELHI, INDIA.

Name : _____________________________________________________________________________
(FIRST) (Middle) (Last)
Passport Size
Age : ____________ Sex : _________

Address : _________________________________________________________________________

__________________________________________________________________________

Tel. / Fax. No. : ________________________________________________________________________________

E-mail : ________________________________________________________________________________
Educational Qualifications: : _________________________________________________________________

SPECIALIZATION : GYNAECOLOGIST SURGEON UROLOGIST
What is your objective of joining this course?

______________________________________________________________________________________________________

______________________________________________________________________________________________________

Date of joining the course :

______________________________________________________________________________________________________

Method of Payment:

_______________________________________________

______________________ (Signature)

WORLD LAPAROSCOPY HOSPITAL
CYBER CITY, DLF PHASE-II, GURGAON, INDIA
Phone: +91(0)1242351555 Mobile: +91(0) 9811416838, 9999677788 | E-mail: contact@laparoscopyhospital.com