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Public Health Research Initiative (PHRI) Research Grant 2016-17
Broad area of specialisation
If other Specify
Area of work *
If other Specify
Name of the candidate *

Correspondence Address:

House No.*
Street/Road 1 *
Street/Road 2
City/District *
State *
Pin Code (6 digit only) *
Phone/Mobile (10 digits Only) *

Permanent Address:

House no. *
Street/Road 1 *
Street/ Road 2
City/ District *
State *
Pin Code (6 digit only) *
Phone/Mobile (10 digits Only) *
Fax
Email *
Date of Birth *
Birth Certificate/any other (file size should not exceed more than 1mb)	Please attach School Leaving certificate or Birth Certificate/any other
Caste/Category
Place of work (Name of Institution)

Academic Qualifications: (From Class 12th Standards onwards)
[*indicate clearly the Name of the Degree at UG and PG level study]

SI.	*Name of the Certificate	*Board/University	*Year of Passing	*Major Subjects Taken	*Percentage of Marks/CGPA	*Rank at the Board or University Examination
*1.	12th	Board/University 12th *	Year of Passing 12th *	Major Subjects Taken 12th *	Percentage of Marks/CGPA 12th *
*2.	Graduation	Board/University Graduation *	Year of Passing Graduation *	Major Subjects Taken Graduation *	Percentage of Marks/CGPA Graduation *
*3.	Post-Graduation	Board/University Post-Graduation *	Year of Passing Post-Graduation *
4.	MPhil / PHD	Board/University MPhil / PHD *	Year of Passing MPhil / PHD *	Major Subjects Taken MPhil / PHD *
5.	Others	Board/University Others *	Year of Passing Others	Major Subjects Taken Others	Percentage of Marks/CGPA Others

Details of Employment:

Name & Address of the employee	Post held	Period from	Period to	Permanent / Temporary / Adhoc	Salary & Grade	Total Experience
Name & Address of the employee 1	Post held 1	Period from 1	Period to 1	Permanent/ Temporary/ Adhoc 1	Salary & Grade 1	Total Experience 1
Name & Address of the employee 2	Post held 2	Period from 2	Period to 2	Permanent/ Temporary/ Adhoc 2	Salary & Grade 2	Total Experience 2
Name & Address of the employee 3	Post held 3	Period from 3	Period to 3	Permanent/ Temporary/ Adhoc 3	Salary & Grade 3	Total Experience 3
Name & Address of the employee 4	Post held 4	Period from 4	Period to 4	Permanent/ Temporary/ Adhoc 4	Salary & Grade 4	Total Experience 4

(file size should not exceed more than 1mb)
Details of Professional Recognitions, Awards, and Fellowships received
Details of professional Training and Research Experience, specifying period
List up to five Publications to which candidate has contributed significantly: (Most recent)
Full list of Publications
Details of work done so far and significance of the scientific contribution
Proposed area of research and brief outline of proposal (under following sub-sections: Origin of the proposal, objectives, brief outline of methodology to be adopted, significance of the proposal in the context of current status in the field, prospects of this work for extending it as a long-term project beyond the tenure of the PHRI)
Name of the Institutions & Department/Center where the PHRI will be availed.

Attach up to 5 most recent publication relevant to the proposed research work
(file size should not exceed more than 1mb)
Attachment 1
Attachment 2
Attachment 3
Attachment 4
Attachment 5

Names and address of three or more References

Sr. No.	Name	Position	Address	E-Mail Id	Phone
1.	Name 1	Position 1	Address 1	E-Mail Id 1	Phone 1
2.	Name 2	Position 2	Address 2	E-Mail Id 2	Phone 2
3.	Name 3	Position 3	Address 3	E-Mail Id 3	Phone 3

**Declaration: It is certified that all information given by me above is true to the best of my knowledge. If any information were found false,
I am aware that my application is liable for cancellation.

Date *

Upload Signature *

Place *

Name *

Contact us

Delhi NCR
Plot No.47,Sector – 44
(Opposite PF Office),
Institutional Area, Gurgaon - 122002
Haryana, India
Phone. 0124-4781400
Fax No. 0124-4781601

PHFI

Public Health Research Initiative (PHRI) Research Grant 2016-17