Application Form

KEM Hospital Research Centre, Pune (KEMHRC)

Application Form for Internship / PGDCR / PhD

Please Note : Kindly write NA whereever Not Applicable or No Answer

Application for *

Name of Applicant *

Gender *

Male

Female

Do not want to Specify

Permanent Address (Write full address)*

Country Code

Phone No (Student) *

Email ID (Of Student) *

Nationality *

For foreign students, do you need assistance in visa process?

Yes

Date of Birth*

You must be at least 16 years old.

Affiliation (Name and Address of University / Institute) *

Email ID (Of Institute) *

If email ID of institute is not available please submit your own email id

Country Code

Phone No (Institute)

Education Details (Write latest first)

Area / Topic of research / dissertation / project / thesis / PGDCR / Internship*

Statement of purpose (What fascinates you to undertake the mentioned study topic)(Max : 500 Words)*

Name of Department to Work With *

How did you come to know about us?(Max : 200 Words)*

Name of Supervisor from your University / Institute *

Please review all your information before submitting. Make sure all required fields are filled correctly.