Apply – PGF

Email Address *

Full Name *

Phone Number

Name of organization/clinic you currently work in (Government or non-government) *

Clinic location in camps or host communities *

Have you completed your MBBS / MBChB and are fully registered with the Bangladesh Medical and Dental Council (BMDC) *YesNo

Please provide your medical registration number. If you do not have a number please explain why not *

How many years since you've graduated from medical school? *

Do you have good command over conversational English? *YesNo

Do you meet the essential requirements for the PGF (See the top of the page to download) YesNoOther

Other

Date available to attend PGF *Cohort C: June 13, 2019 - September 9, 2019Cohort D: September 19, 2019 - December 9, 2019

Can you attend either Cohort C or D if accepted? *YesNo

If you answered no to above, please explain

Does your supervisor/organization consent to you attending the PGF? *YesNo

Please describe in detail why you are interested to attend the PGF and how this will benefit your career *0 / 500

If accepted onto the PGF, do you agree to attend a minimum of 75% of the lectures and participate in at least 2 clinical shadowing opportunities? *YesNo

If accepted onto the PGF, do you understand and accept that if you do not attend more than 75% of the PGF you will not pass the PGF? (See Participant Form for list of holidays and days off) *YesNo

Please provide any additional comments

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