Application Form

The form given below is for information purpose. How ever actual form shall have to be 
obtained from the office. Click here to Download the Application Form.

Fellowship requisites

Dear Dr.

A.      FOLLOWING ARE PRE REQUISITES FOR CONSIDERATION OF FELLOWSHIP

1.       Must be a qualified dental surgeon. B.D.S., M. D.S. (Recognized by DCI)

2.       Age must be 35 or above as on January 31^st, of the year of application.

3.       a) Membership of Indian Dental Association, minimum 5 years as a Registered Dental
Surgeon of good standing/Life Membership IDA Head Office.

b) For officers of the armed forces, the membership should not be below 3 years.

4.       Service to the cause of dental association, profession, education and research and
or to the community/nation.

B.      FEES FOR OBTAINING PRELIMINARY APPLICTION FORMS

1.       Preliminary application form will be sent to you on receipt of the fee of Rs. 350/- 
(Postage /Processing fee).

2.       Cheque/DD for Rs.350/- should be drawn in favour of ‘INTERNATIONAL COLLEGE 
OF DENTISTS, INDIA SECTION, NEW DELHI.

3.       Please add Rs.50/- for outstation cheques.

C.      PROCEDURE FOR SUBMITTING PRELIMINARY APPLICATION FORMS

1.       Fill up all the columns in preliminary application form (in duplicate).

2.       Attach the following along with the preliminary application.

-          Copies of certificates (BDS/MDS etc. & Registration Certificate up to date)

-          Copies of Publications

-          Proof of membership claimed/supporting documents/credentials claimed
in each column.

-          Two latest passport size photographs.

-          Certificate of IDA as having continuous/good standing membership of 5 
years from IDA (Head Office)/Life Membership IDA Head Office and 3 years for Armed Forces in active service.

-          Detailed bio-data.

D.      LAST DATE FOR RECEIPT OF PRELIMINARY APPLICATION FORM

January 31^st each year.

Application received after January 31^st will not be considered for grant of fellowship for the 
particular year.

E.       FEE:- Elected fellows of I.C.D. India & Sri Lanka Section have to sign undertaking for

                  Submitting their dues as follows.      

a)   Life Fee for India Section – Rs.15,000/- (Fifteen thousand only)

b)   A Deposit of Rs.10,000/- towards the payment in US Dollars for the following:
Central Share to Head Office, USA - @ US$30.00 per year after the Induction year.
Induction fee for USA (Head Office) US$50.00 for the year of Grant of Fellowship.
(This includes your Induction fee of Head Office US$50.00 and Central Share of US$30.00 per year)
Total Demand Draft of Rs.25,000/- (Twenty five thousand only) in favour of “International College of Dentists, India Section, New Delhi”.

With regards and wishing you all the best,

Yours Sincerely,

DR.J.C.CHANDNA
SECRETARY GENERAL, I.C.D.

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Application Form 

INTERNATIONAL COLLEGE OF DENTISTS
U.S.A.
INDIA & SRI LANKA SECTIION (6)
PRELIMINARY FORM

Objective:

Our purpose is to seek, with maximal adequacy, comprehensiveness and fairness, and evaluation of the 
qualifications of a prospective fellow, which will portray his present eligibility and readiness for election 
and, in the case of the younger applicant, his promise of potential achievement.

In addition to formal biographical information, any assistance in the form of letters of endorsement or 
brief comment and descriptive detail will be of high value.

Letters of endorsement or of appraisal (attached hereto or separately available):

)

)

)

Additional comments (signed and giving basis of approach for opinion).

Name of candidate :-

Address:-

Pin Code:-                    Phone No. (Off)                           (Res)

Recommendations (or comments) of Zonal Regent:

Date_____________

Dental Association Memebership:

                                                                                                Secretary General

                                                                                                           Date

    Credentials report:                                                                                         Remarks

  1

  2

  3

  4         Chairman

Received back on :            1)                     2)                      3)                       4)

Credentials:    in favour……….
                      Against

Decision by board of Regents:

President./Presiding officer

INTERNATIONAL COLLEGE OF DENTISTS

INDIA & SRI LANKA SECTION (6) 

1.       Name_______________________________________________________

2.   Address_____________________________________________________  
Pin Code__________________  Phone No._________________________

3.       Place and Date of Birth_______ __________________________________

4.       Attendance at school:

(a) School______________________ Years attended ____________
     Dates __________________________________

(b) Higher Secondary/Matriculation/Sr. Cambridge passed. State year ____

5.       Attendance at college:

(a) College____________________________ Years attended ___________     
     Dates _____________________________

(b) If graduated, state degree _________________________ Year ______      

6.       Attendance at Dental college:

(a) College ____________________________Years attended __________ 
      Dates______________________________

(b) If graduated, state degree ________________________ Year_______         

7.       Attendance at Medical School/College :

(a) School/College ________________ _____Years attended ___________ 
     Dates______________________________     

            (b) If graduated, state degree_________________________  Year_______              

8.       Attendance at professional or other school for postgraduate or graduate work:

(a) School__________________________ Nature of study _____________
     Dates____________________________                                

            (b) If graduate degree or diploma received, so state ___________________ 
             Year ________ 

9.       Attendance for p.g. study at non-acad. Institution, clinic or with priv. Instructor:

(a) Instr., etc. __________________Nature of study __________________
     Dates ______________________                               

(b) If diploma or certificate rec’d, give detail__________________________
     Year______ 

10.       Honorary Degrees___________________ College or Univ. ______________
Date _____________________________  

11.   Hospital Service:

           (a) Internee__________ Staff Member ____________
             Other capacity ________

           (b) Character of service_________________ Time of service_____________

     12.   Years in general practice___________________Date___________________

     13. Years in special practice___________ Specialty _______________________
           Time devoted to specialty_________________ 

14.   Dental society or other professional memberships (active): 
(Attach certificate from the Secretary, giving the details of memberships and offices held.)
 ______________________________________________ Date __________  
 ______________ ________________________________ Date __________
 ______________ ________________________________ Date __________
 ______________ ________________________________ Date __________

15.   Special professional contributions:

A)      Teaching

(a)    Academic (schools or colleges-dental, medical, etc):

School______________________ Title _________________
Date_________________
Subjects taught_______________ Time devoted _________

(b)    Non-academic - clinics, study clubs, conf. Or society meetings ets:

                                 Auspices – and subject taught ______________________________ 
                                 Date_______________ 
                                  ______________________________Date_______________
                                  ______________________________Date_______________

B)      Research:

(a)    Clinical investigations (state overall plan):

________________________________________________________
________________________________________________________
___________________________________

(b)    Non-clinical (academic, laboratory, etc:)

_______________________________________________________
___________________________________________Lectures given 
(Professional) itemize or summarize lecture activities; (attach extra 
page, if necessary)

               __________________________________________________

C)     Publications :(Itemize; extra page if necessary ; state title, journal, year, page):

__________________________________________________________________
__________________________________________________________________
____________________________________

D)     Organizational activities- professional societies, etc.- promotion, services, etc.:

________________________________________________________

Official positions held _______________________________________

________________________________________________________

                       Honors received, etc. _______________________________________

Such as

(a)    Public health or public welfare – local, general; e.g. mental health; cancer,
 etc; Volunteer work (state or social agencies, etc)

(b)    Civics (political, social, economic, community planning, etc).

(c)    Religious activites

(d)    Other evidences of concern for needs of youth, indigent, handicapped, aged, etc.
 ________________________________________________________________
_________________________________________________________________
_________________________________________________________________       

17.   Non-professional activities relating to the humanities: Interest in, or contribution to – 
literature, art, music, travel, recreations, etc._________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

      18.   Experience in other vocational areas, skills, etc.; e.g. teaching (general), business, industry,
       agriculture ___________________________________________________________________
        ____________________________________________________________________________
       ______________________________________________________

    19.   Service with armed forces, if any ______________________________________________

__________________________________________________________________________
__________________________________________________________________________
____________________________________

      20.   Other information related to personal background, training, interests, professional or 
          individual philosophy, activities, goals ____________________________________________ 
          ___________________________________________________________________________
         ____________________________________________________________________________
         ________________________________________________ 

21.   a)  Registration No.:

b)      Date of registration:

c)       State with which registered:  
 (photocopy of - registration certificate up to date)

22.   One copy, photograph quarter size, glazed

                                                                                                                         Signature.

Note:- If additional space is needed for any item- attach extra sheets.