Application Form for Palliative Care Award 2012 of INR 100000 Rs. and Plaque for South East Asia Region instituted by Cancer Aid Society

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Cancer Aid Society is an ISO 9001:2008 Accredited, National, Secular, Social Charitable Organization, working since 1987 on Palliative Care, Tobacco Control, Advocacy, Prevention and Control of Cancer and Non Communicable Diseases in tune with the guidelines of National Cancer Control Program of the World Health Organization.

Application/ Nominations are invited from Doctors, Paramedical Staff and Social Workers with "Demonstrative Leadership in the field of Palliative Care for the Cancer Patients" from India, Bangladesh, Bhutan, Nepal, Pakistan, Afganistan and Sri Lanka.

Application can be made by filling this form along with the references and verifiable evidences through media and pictures in order to identify the leadership of the applicants/ nominees.

Last date of Application is 12.00 Hrs. (India Time) of 30th November 2012.

CAIDS PALLIATIVE CARE AWARD - 2012 (Rs. 100000. and Plaque) will be presented at the 20th International Conference of the Indian Association of Palliative Care - February 2013 to be held at Bengaluru India.

2011 Award went to Dr. Bishnu Dutta Paudel of Nepal.

Name of Applicant *

First Name Middle Last

Address with PIN code *

H.No. Street City State Country Pin Code

Phone Number *

Country code Phone number

E-mail *

Organization *

Name Address State Country

Role/ Designation *

Area of work *

Cities States Countries

Activities with Timeline *

Time Period Details with Evidences

Achievements (Quantitative) *

Time Period Details of Beneficiaries etc. with Evidences

Achievements (Qualitative) *

Time Period Details of Stakeholders / beneficiaries with Evidences

2 References with Contact Details *

Name Address Contact Details Email, Phone No.(Refree may kindly substantiate the work of the applicant)

Photograph *

Any Other Information *

Please send a softcopy of the form and photograph to palliativecare@canceraidsocietyindia.org

Your entry will be considered if the form is not uploaded properly and we will inform you regarding the same.

Published by- Dr. D.P.Gupta, President Cancer Aid Society - India

Cancer Aid Society
Head Office
First Floor, Regency Avadh Complex,
Chowk, Lucknow, UP. Pin - 226003
Phones: 91-522-2259157, 4043686, 3255278
FAX 91-522-2259239
Email: dpgupta@canceraidsocietyindia.org; help@canceraidsocietyindia.org
Website: www.canceraidsocietyindia.org

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