Application to join the Peradeniya Writing Club of the Research and Development Division of the Faculty of Medicine

Name :

Email address, mobile No. :

Faculty and Department :

Designation :

Type of study : Epidemiological ☐ Laboratory ☐ Case study ☐

Clinical ☐ Educational☐

Other ☐please state:

Brief description of study :

Tentative topic of the intended paper :

Target journal (if any) :

Current stage of the study : Analysed data available☐

Written in point form☐

Some sections written☐

1st draft ready☐

Other☐specify:

Kind of support required of the mentor :

Preferred gender of the mentor : Female☐ Male☐ No preference☐

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Applicant’s signature Approved by the Head of the Department

If the current work is part of a postgraduate degree, approval of the supervisor is required.

I, …………………………………………………………………………………Supervisor of the above named, do hereby consent to him/her participate in the Peradeniya Writing Club.

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Signature of the Supervisor