Application form for the IAPC’s Foundation Course in the Essentials of Palliative Care (FCEPC) Name of the IAPC authorized course centre through which you are submitting the application Select Course Centre * —Please choose an option—Andhra Pradesh: Homi Bhabha Cancer Hospital and Research Centre (HBCHRC), VishakhapatnamArunachal Pradesh: Tomo Riba Institute of Health and Medical Sciences (TRIHMS), NaharlagunAssam: Dibrugarh Cancer Centre, DibrugarhAssam: Durganath Hemoprova Hazarika Memorial Palliative Care Clinic, GuwahatiAssam: State Cancer Institute, GuwahatiAssam: Dr. B. Borooah Cancer Institute, GuwahatiAssam: Cachar Cancer Hospital and Research Centre, Meherpur, SilcharBihar: Indira Gandhi Institute of Medical Sciences (IGIMS), PatnaBihar: All India Institute of Medical Sciences, PatnaChandigarh: Government Medical College & Hospital, ChandigarhChandigarh: Postgraduate Institute of Medical Education and Research, ChandigarhChhattisgarh: Hope Health & Beyond, Pain & Palliative Care Centre, RaipurDelhi: Max Super Specialty Hospital, New DelhiDelhi: Dharamshila Rahat Medical Centre, New DelhiDelhi: All India Institute of Medical Sciences, New DelhiGujarat: Gujarat Cancer & Research Institute (GCRI), AhmedabadHaryana: Fortis Memorial Research Institute, GurugramJharkhand: Kosish, BokaroKarnataka: St. John's Medical College & Hospital, BengaluruKarnataka: Kidwai Memorial Institute of Oncology (KMIO), BengaluruKarnataka: Bangalore Hospice Trust – Karunashraya, BengaluruKarnataka: Samzios Palliative Care and Research Institute, KalaburagiKarnataka: JSS Medical College and Hospital, MysuruKarnataka: Swami Vivekananda Youth Movement, MysuruKerala: Institute of Palliative Medicine (IPM), KozhikodeKerala: IQRAA International Hospital and Research Centre, KozhikodeKerala: Amrita Institute of Medical Sciences & Research Centre, ErnakulumKerala: Malabar Cancer Centre, ThalasseryKerala: Regional Cancer Center, ThiruvananthapuramKerala: Believers Church Medical College, ThiruvallaKerala: Aster Medcity, KochiMadhya Pradesh: Sri Aurobindo Medical College and PG Institute, IndoreMaharashtra: Cipla Palliative Care and Training Centre, PuneOdisha: Acharya Harihar Post Graduate Institute of Cancer (AHPGIC), CuttackOdisha: All India Institute of Medical Sciences, BhubaneswarOdisha: Amrit Dhara Palliative Care Centre, BhubaneswarOdisha: Institute of Medical Sciences & SUM Hospital, BhubaneswarPunjab: Sri Guru Ram Das University of Health Sciences, AmritsarRajasthan: Bhagwan Mahaveer Cancer Hospital and Research Centre, JaipurRajasthan: Mahatma Gandhi Medical College and Hospital, JaipurRajasthan: SMS Medical College, JaipurRajasthan: All India Institute of Medical Sciences, JodhpurTamil Nadu: Sudharsana Palliative Care, TiruchirappalliTamil Nadu: Lakshmi Pain and Palliative Care Trust, ChennaiTamil Nadu: Cancer Institute (WIA), ChennaiTamil Nadu: PSG Hospitals OR Coimbatore Cancer Foundation, CoimbatoreTelangana: Kumudini Devi Palliative Care Centre, HyderabadUttar Pradesh: Sanjay Gandhi Post Graduate Institute of Medical Sciences, LucknowUttar Pradesh: King George's Medical University, LucknowUttarakhand: All India Institute of Medical Sciences, RishikeshUttarakhand: Cancer Research Institute, DehradunWest Bengal: Narayana Super Speciality Hospital, HowrahWest Bengal: Shanti Palliative Care Centre, Siliguri Name of the candidate First Name * Middle Name Last Name * Qualification of the candidate Select your qualification * MBBSBDSBSc NursingGNM Upload your certificate * Only jpg, jpeg, png and pdf files of maximum 3 mb size allowed Contact details of the candidate Your email address * Your mobile number * Address for correspondence with PIN code * Name of the organization you are currently affiliated with Address of the organization you are currently affiliated with Please scan the QR code to make payment UPI ID: IAPC399@SBI Amount paid (Rs) * —Please choose an option—Rs. 10,000/- (For Doctors)Rs. 4,000/- (For Nurses) Date of transaction * Transaction number * Name of your bank from where the transfer was made Name of the branch of your bank Upload transaction screenshot * Only jpg, jpeg, png and pdf files of maximum 5 mb size allowed Please prove you are human by selecting the heart. < Back Share this:FacebookTwitterLinkedInWhatsAppPocketPrint