Fellowship Application Form

Category of Fellowship *

Associate (ACHI)

Member (MCHI)

Fellow (FCHI)

Section A: Personal Information

Full Name *

Date of Birth

Gender *

Nationality

State of Origin

Contact Address

Phone Number

Email Address *

Section B: Area of Specialization * (Select ONE only)

Community Reproductive, Maternal and Newborn Health

Community Child Health and IMCI

Community Mental Health

Community Eye Care

Community Epidemiology and Disease Control

Community Disaster and Humanitarian Emergencies

Community Nutrition and Dietetics

Community Ear, Nose and Throat (ENT) Care

Section C: Educational Qualifications

List from most recent

Institution

Qualification

Certificate

Year

Section D: Professional Qualification & Licensure

Professional Body

Registration Number

License Status

Section E: Professional Experience

Employment Status

Current Job Title

Employer/Organization

Years of Experience

Areas of Practice Relevant to Specialization

Summary of Professional Experience

Section F: Contributions to Community Health

Key Projects/Programs

Research/Publications

Awards/Recognitions

Section G: Continuing Professional Development (CPD)

Trainings/Workshops (Last 5 Years)

Conferences/Seminars

Section H: Personal Statement (Max. 300 words)

Explain your interest in the selected specialization and how the fellowship will contribute to community health practice.

0 / 300 words

Section I: Referees

Referee 1

Name

Position

Phone

Email

Referee 2

Name

Position

Phone

Email

Supporting Documents

Accepted formats: PDF, JPG, PNG (max 5MB each). Passport photo max 2MB.

Passport Photograph

Curriculum Vitae

Academic Certificates

Professional License/Registration

Evidence of Contributions

Section J: Declaration

I hereby declare that the information provided is true and correct. I understand that false information will lead to disqualification.

Signature (Full Name) *

Date *