Page 28 - Prospectus Felloship and Diploma in Minimal Access Surgery

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Application For Laparoscopy Training

Integrated Diploma & Fellowship in Minimal Access Surgery (D.MAS & 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