To,

The Chairperson,

__________________________________________________,

Dear Sir / Madam,

The below mentioned fellowship candidates training at our Institute, would like to take the IAP Neonatology Chapter Fellowship Exam Scheduled on ______________ at _________________.

The details of the candidates and their exam fee payment are given below –

1)      Candidate’s name - ____________________________________________________

Qualification - _________________ Date of Appointment - ____________________

                                                       (Please attach a copy of the appointment letter from Institute)

Completed 85% of the prescribed period of training: Yes / No

Performance / Conduct / Internal assessment – Satisfactory / Unsatisfactory

Clinical study completed – Yes / No

Exam fee amount – Rs. 7000/- (Seven thousand only) Transaction No: ___________________

Bank _____________________________________ Date of Transaction: __________________

2)      Candidate’s name - _____________________________________________________

Cell No. - _______________________ Email ID - _____________________________

Qualification - _______________________ Date of Appointment - ______________

                                                         (Please attach a copy of the appointment letter from Institute)

Exam fee amount - Rs. 7000/- (Seven thousand only) Transaction No: ____________________

Bank _______________________________________ Date of Transaction: _________________

Completed 85% of the prescribed period of training: Yes / No

Performance / Conduct / Internal assessment – Satisfactory / Unsatisfactory

Clinical study completed – Yes / No

__________________________________                _____________________________

Signature of Institute Head                                                Signature of Fellowship Coordinator