Step 3: Fellowship Application Form

Application form for STEP-UP (Sustained Training & Education Project - Upgrading Physician Skills) fellowship program
Please provide your full name*

First NameLast Name
Please enter your email id*
Please enter your primary contact number*
Please enter a valid phone number.
Please enter your date of birth*

YearMonthDay
Date
Please provide your permanent address*

Street Address

Street Address Line 2

CityState

Zip Code
Copy of Permanent Residence Proof Certificate" or "Domicile Certificate"

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Please select your gender*

MaleFemaleN/A
Please enter your MCI registration number*
Please select your highest level of qualification*

DOMD/MSDNB

Whether you had any prior training /fellowship

What kind of current healthcare setting are you working in? (Choose only one)*

Rural multispecialty hospitalPeri-urban multispecialty hospitalUrban multispecialty hospitalOwn practice/clinic

Please list your employment history *

Have you been the author of any research publication? (Choose only one)*

Independent ResearchIndependent Article/Case studiesJoint AuthorshipNone
How many case studies will you include or share in the fellowship program? (choose only one)*

>32-31None
Please write a cover letter addressed to the CEO, DakshamA Health*
Please write Statement of Purpose*
Please upload your Statement of Purpose*

please upload either a pdf or word file
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Please upload 2 Letters of Reference*

please upload either a pdf file
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Please upload your degree certificates.*

(Max size 3 MB)
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Please upload proof of nationality*

you have to upload your Passport/Aadhaar Card (Max size 3 MB)
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Please verify that you are not a robot*
Privacy Policy

DakshamA Health is committed to protecting the privacy and security of your personal information (‘personal data’).As a general rule, this website does not collect personal information about you when you visit the site. Most of the information we hold comes from your application. We process your data for the purpose of processing and assessing your application for study, and for purposes related to your application, such as assessing your eligibility for the STEP - UP program.

We will delete a fellow's data once he/she completes the fellowship program and meets all requirements (academic and institutional, including any relating to legal, accounting, or reporting).
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Application form for STEP-UP (Sustained Training & Education Project - Upgrading Physician Skills) fellowship program