Serial No. ... ... ...
INTERNATIONAL INSTITUTE OF HEALTH MANAGEMENT RESEARCH, NEW
DELHI
Plot 3 Sector 18 A, Dwarka, Delhi 110075
APPLICATION FORM
Fellow Program in Management
Batch 2023- 2026
Instructions:
• All information asked for should be provided. Incomplete forms will be rejected.
• In case of paucity of space, you can attach an additional sheet mentioning the item
number responded.
• The application fee is 1000/- non- refundable and the payment can be made through
DD/RTGS/NEFT
Institute’s Bank Details
Bank Name: INDUSIND BANK
Bank Address: SANGAM COMPLEX, GR. FLR. CHURCH ROAD, JAIPUR -302001 Bank Account
No.: 100148774167
Bank IFSC Code: INDB0000016
Bank Account Holder Name: International Institute of Health Management Research
Address of Account Holder: Plot No.3, HAF Pocket, Phase-II, Sector-18A, Dwarka,
New Delhi-110075
List of the self-attested documents to be attached with the application for admission:
S.No List of Documents Place a Tick
1 10 + 2 mark sheet
2 Post-Graduation degree/ B.E/B.Tech degree/ final Mark sheet
3 UGC-Net/ CSIR scholarship award letter
4 Work Experience
5 Pan Card or Aadhar Card copy
6 2 Copies of Self attested photos
7 Abstract of proposed study (5000 words)
How to Apply: Submit the filled form with documents and application fee details to
FPM@iihmrdelhi.edu.in
IIHMR Delhi
FPM 2023- 2026
Serial No. ... ... ... …
Affix Photo Here
Fellow Program in Management 2023- 2026
A. Biographical Information (Please fill all the details in capital letters only)
Title: Mr. Ms. Dr. Others (Please Specify)
i. Name:
First Name
Middle
Last Name
ii. Gender: iii. Date of Birth: iv. Nationality: v. Blood Group:
Male Female DD MM YYYY
vi. Father’s/ Husband’s Name (Do not write Sri/Mr./Dr. etc.):
vii. SC/ST/OBC/ General Category ____________
viii. Contact Details for Admission Procedure
Address for Correspondence
City
State Pin
Contact No: Country Code STD Code Phone No
Landline - -
Mobile No
Permanent Address
City
State Pin
Contact No: Country Code STD Code Phone No
Landline - -
Mobile No:
Email ID:
IIHMR Delhi 2
FPM 2023- 2026
B. Application Fee Details:
a) DD DD No. …………………… Date ………………………. Drawee Bank ……………………
b) RTGS/ NEFT Transfer No …………………… Date ……………………Account Holder Name………………..
C. Academic Performance: (Starting from 10th Standard)
S. No. Name of Examination Name of Board/ Year of % of Marks Division
University Passing (Aggregate)
1
2
3
4
5
D. Have you cleared UGC-NET or CSIR Scholarship Exam? Yes/ No. If Yes, the name of the exam
and date of passing the exam _______________________________________________
E. Details of Past and Present Work Experience
S.No. Organization Designation/ From To Duration
Position Held (months)
1
2
3
4
E. Specialization you are opting for (Tentatively choose one)
a. Health Management b. Hospital Management c. Health Information Technology
Management
___________________
F. Mention the proposed topic of study (Attach an abstract of about 5000 words):
_________________________________________________________________________________
_________________________________________________________________________________
G. What are your expectations from the program (Mention in few words): ___________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
H. How did you come to know about the program (Select top two sources. Place a Tick Mark)
Word of Mouth IIHMR Delhi Website
Linked-in /Twitter/Facebook/ Instagram Alumni
Newspaper/ Magazine Any other
IIHMR Delhi 3
FPM 2023- 2026
SECTION – B
Declaration by the Applicant
I hereby certify that the above information provided by me is correct and, I understand that if
the information is found to be incorrect or false, then I will be automatically debarred from the
selection/admission process without any correspondence in this regard. I also understand that
the application/registration/short listing does not guarantee admission in the institute. I accept
the process of admission undertaken by the institute and I will abide by the decision taken by
the institute authorities. I have checked the information carefully. I will, on admission, adhere
to the rules and discipline of IIHMR. I hold myself responsible for the dues and payment of fees.
I confirm that there is no legal case filed against me and will provide the necessary information
as and when required by the institute.
I have also provided the names of two people who can provide an academic reference in support
of my application.
Reference 1 Reference 2
Name
Designation
Affiliation
Contact No
Email
________________ ________________ _________________
Date Signature Name of the Applicant
……………………………………………………………………………………………………………………………………………………
For Official Use
Application Verified By : Date
Application Approval Status: Date
IIHMR Delhi 4
