Date received by WVS Hicks ITC [_____________]

REGISTRATION FORM for SPECIAL ITC COURSE at WVS Hicks ITC GOA in JANUARY 2018
ANAESTHESIA & DIAGNOSTIC IMAGING
NOTE: Please fill the form carefully and return to WVS Hicks ITC as soon as possible, by post
along with a donation of Rs. 2,000, by Demand Draft only, in favour of “Worldwide Veterinary
Service India”, payable in Udagamandalam, SBI Branch Code 891, Nilgiris district. The
participants for the courses are selected and placed in the order of receiving suitable
applications (refer to the information package for details on who can apply). After selection, the
participants will receive a confirming email. Please note that registration once made cannot be
transferred to another person.
1. Name of the participant
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— present occupation
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— phone number
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— email address
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— postal
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-- Gender: ……………………… Age: ……………………… Rabies Vaccination Details:
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2. Charity/ municipality/ agency where employed at the moment
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3. Name and phone number of contact person in-
charge………………………………………………………………………………………………….
— email address of a contact person in
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— postal
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4. Working experience - please indicate number of years as well
— In general
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— In animal charities
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— In ABC programs
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5. Current situation and future plans.
Please, explain briefly the type of anaesthesia and diagnostic imaging that you use at your
workplace, and what is being done at the moment and by whom.
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Please, explain how much time per month you expect to spend in working at a charity/ clinic to
improve the welfare of animal in India.
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Please, explain freely how you expect this course to benefit you in your veterinary work.
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