INSTITUTE OF HUMAN REPRODUCTION

Bharalumukh, Guwahati – 781 009, Assam, India

Ph: +91-361-2482619, 2482621, 098641 03333
Email: office@ihrindia.com, Website: www.ihrindia.com

(Please fill up the form in BLOCK LETTERS)

1. Name :

2. Permanent Address :
Affix your recent
passport size photograph

Phone No. :
Fax No. :
Email :

3. Date of Birth :

4. Sex :

5. Nationality :

6. Marital Status :

7. No. of Children :

8. Any Medical Disorder :

9. Educational Qualifications

 UNDERGRADUATION
o Nature of Undergraduate degree :
o Date of completion :
o College from which graduated :
o University :

 POST GRADUATION
o Nature of P.G. Degree :
o Date of completion :
o College from which graduated :
o University :
 INSTITUTE OF HUMAN REPRODUCTION
Bharalumukh, Guwahati – 781 009, Assam, India
Ph: +91-361-2482619, 2482621, 098641 03333
Email: office@ihrindia.com, Website: www.ihrindia.com

10. Any other qualification obtained :

11. Any previous experience in infertility management: Yes / No

12. Any previous experience of Ultrasound: Yes / No

13. Any previous experience of Laparoscopy Surgery: Yes / No

14. Ever handled Human Gametes: Yes / No If Yes : Sperm / Oocyte / Both

15. Are you a Clinical / Laboratory Scientist

16. Payment details:

Rs. _____________________of_____________________(Name of Bank), dated_________
D/d Number

Other Information

1. Course Fee: Rs. 1, 00,000/- or USD 2500

2. The whole course fee should be sent in advance by demand draft in favour of “INSTITUTE
OF HUMAN REPRODUCTION” payable at Guwahati, India.
3. Periodical review of the applications received is made and selected candidates will be
informed of the allotted course and batch well in time.
4. Failure to join the allotted course under any circumstances, will entail cancellation of the
allotment, Fees paid will stand fortified (no refund), and candidates, have to wait for their
turn, if willing to undergo training in future batch, as fresh incumbent only, after due
application, fees etc afresh.
5. For any further details / clarifications / help contact Dr. Deepak Goenka at:

Dr. Deepak Goenka, MD

INSTITUTE OF HUMAN REPRODUCTION
Bharalumukh, Guwahati- 781 009, Assam, India
Ph: +91-361-2482619, 2482621, 098641 03333
Email: office@ihrindia.com