Please affix a passport size photo here
1. Name of applicant :
2. Age & Date of birth :
4. College (Address) & University :
5. Course & Year :
6. Period for which training requested : December-March / April-July
7. Residential address with E-mail &
phone No :
8. Undertaking from applicant and head of the institution
a) Certify that Mr/Ms is a bonafide student doing .. course in our department.
b) Certify that the name of the supervisor at the Regional Cancer Centre and the Division of Cancer Research, Regional Cancer Centre will be included as the name of the guide and place of work carried out respectively in the certificates issued from the College/ University and also in the declaration of the student.
c) Certify that result generated during the training period will remain in absolute ownership of RCC.
d) Certify that work carrying out in the Division of Cancer Research, RCC, will not be published in any context without the prior permission of the supervisor and the director of the Regional Cancer Centre.
Name of the applicant with Signature Name & Designation of Head of the Department with Signature
I certify and endorse that all the above information provided is correct and understand that any instance/s of flouting of this agreement will be taken seriously and will be liable for legal action.
Name & Designation with Signature
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