APPLICATION FORM
FOR FOGSI RECOGNISED/ADVANCED /BASIC INFERTILTY/
IUI TRAINING COURSES
FOGSI HAS THREE TRAINING COURSES IN INFERTILTY VIZ..
1.IUI & Stimulation Protocol
2. Basic Infertilty Training Course
3. Advanced Infertilty Training Course
This Course is for Fogsi Members only. All Course fees paid by a demand draft or bankers cheque payable at Mumbai in favor of FOGSI. All applications should be sent to Dr. Kumud Pasricha, Shivam Fertility & IVF Center Kapurthala Chowk Jalandhar
Sur Name Dr. ______First Name: ______
Middle Name: ______
Sex:______Age:_____ Qualification:______
Address:______
City______State ______Pin Code______
Telephone No with code ______Mobile No.______
Sur Name Dr. ______First Name: ______
Middle Name: ______
Sex:______Age:_____ Qualification:______
Address:______
City______State ______Pin Code______
Telephone No with code ______Mobile No.______
Member of ______OBS & GYN Society
D/D NO. ______Drawn on______
Rs.______(In words) ______Date:______
No Of days ______Preferable Months______
Course Fees
1.IUI & Stimulation Protocol - 2 days Rs. 3000.00
2. Basic Infertilty Training Course - 7 days Rs.15000.00
3. Advanced Infertilty Training Course -14 days Rs.25000.00
These are basic charges + 14% taxes so the charges will be:-
Rs. 3000.00 + 14%Service Tax = Rs.3420.00
Rs.15000.00 + 14%Service Tax = Rs.17100.00
Rs. 25000.00 + 14%Service Tax =Rs. 28500.00
Hotel Accommodation Required Not Required
Incomplete form will not be accepted
Signature of applicant
FOGSI RECOGNIZED IUI & OVULATION INDUCTION TRAINING DETAILS
Duration – 2 days
Course Fee Rs. 3000.00 + 14% service tax
Date & Timings for Training ------between ------
Course Detail-
Day-1 Basic evaluation of infertile couple, Ovulation Induction Proctocol
Day-2 IUI Focus, Hands on IUI
FOGSI RECOGNIZED CENTER FOR BASIC TRAINING IN INFERTILTY DETAILS
Duration -7 days
Course Fee Rs. 15000.00 + 14% service tax
Date & Timings ------between ------
Course Detail (Day 1-2) same as above
Day -3,4,5 Focus on Sono graphy in Infertility
Day -5,6,7 Fertility enhancing Basic endoscopic surgery
FOGSI RECOGNIZED CENTER FOR ADVANCE TRAINING IN INFERTILTY DETAILS
Duration -14 days
Course Fee Rs. 25000.00 + 14% service tax
Date & Timing ------between ------
Course Details (Day 1-7) same as above
Day 8 –to- 14 Focus on IVF/ ICSI Lab Setup as per national guide lines, development of fertilization OPU , embryo Transfer , Cryopreservation of embryo & semen in lab.
COURSE FEE INCLUDES
1. Two weeks training
2. Tea/ Coffee/ Lunch
3. Course Material, CD of Setting ART unit, Copy of current Guide lines
4. Certificate of attendance will be given to all delegates along with the exam result.
5. Does not include stay or travel to the center.