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Certificate Course in Evidence Based Diabetes Management (CCEBDM)

Participant Enrolment Form

Instructions:

Need to upload scanned copy/screenshot of passport size photo, MCI/NMC/State Council Certificate, MBBS Degree, Payment Transaction Details (in JPG, JPEG, PNG and PDF format).
Maximum size to upload the scanned/screenshot of documents would be 250KB.
All the mandatory fields (having *) are required.

SECTION I: PERSONAL DETAILS

Participant Name *

Gender *

Date of Birth *

Mobile *

Whatsapp Number *

Email *

Photo *

Alternate Email

Current Affiliation *

If Others, Please Specify

Medical College/Teaching Affilliation

Yes

No

If Yes

Location of Practice *

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SECTION II: PLACE OF WORK

Place of Work *

Street *

Landmark *

City *

District *

State *

Pincode *

SECTION III: RESIDENTIAL ADDRESS SAME AS ABOVE:

Residence Address *

Street *

Landmark *

City *

District *

State *

Pincode *

Preferred Mailing Address *

SECTION IV: MCI/NMC REGISTRATION DETAILS

MCI/NMC Registration No. *

Registration Certificate *

Registration Date *

State *

SECTION V: QUALIFICATION

MBBS *

College/Institution/Board/University

Year of Passing

Attach Proof

MD/MS

College/Institution/Board/University

Department

Year of Passing

Attach Proof

DNB

College/Institution/Board/University

Department

Year of Passing

Attach Proof

DM/PhD

College/Institution/Board/University

Department

Year of Passing

Attach Proof

Diploma

College/Institution/Board/University

Department

Year of Passing

Attach Proof

Others

College/Institution/Board/University

Department

Year of Passing

Attach Proof

MBBS Outside India *

SECTION VI: PROFESSIONAL/CLINICAL EXPERIENCE

Total Professional/Clinical Experience: *

Year

Month

Total years of experience in dealing with diabetic patients *

Year

Month

Average no of patients treated per month

Out of all, how many are diabetic patients

SECTION VII: FACULTY/CENTER PREFERENCE

Preferred State *

Preferred Center *

Preferred Faculty *

* Confirmation subject to availability of seats

SECTION VIII: TRANSACTION/PAYMENT DETAILS

Mode of Payment (NEFT, UPI etc) *

Transaction Reference No. *

Payment/Transaction Receipt *

Date of Payment/Transaction *

Bank Name *

Branch Name *

I hereby declare that the above mentioned information, which I have provided, is true to the best of my knowledge. I shall participate in the online sessions organised once in a month on weekend and will devote self-reading time for the entire twelve modules and participate in the assessments, organised by the offering institution. I give my consent for publishing my feedback/testimonial which I will provide to the Secretariat in any report or publication produced by PHFI. I also give my consent for sharing other course information on my mobile number and email id. I understand that CCEBDM is not a degree or diploma but a certificate course with the objective of training doctors in the prevention & management of diabetes. Successful participants are advised not to mention/call themselves as diabetologists/endocrinologists anywhere after completion of this course. I also understand that this certificate course is not a recognised Medical Qualification, under section 11 (1) of the Indian Medical Council Act 1956 and the Institution offering this course is neither a medical college or a university nor offering the course in accordance with the provisions of the Indian Medical Act/University Grants Commission Act.

Plot No 47, Sector 44, Institutional Area, Gurugram, Haryana – 122002

+91-7982162863, 9868090590, 9699824760, 96460003358, 9810435824

diabetestraining@phfi.org

www.phfi.org, www.ccebdm.org

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