Parsottam Mamorial Trust (PMT) · Varanasi, U.P.

ECRRB Membership Application

Ethical Committee & Research Review Board

Use this form to apply for membership on the Ethical Committee & Research Review Board (ECRRB) of Parsottam Mamorial Trust (PMT), Varanasi, U.P. Please keep your CV, list of publications, and any relevant certificates ready to upload before you begin. All fields marked with * are required.

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Applicant Details

Full Name*

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Date of Birth*

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Passport Photo (Optional)

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Current Designation / Occupation*

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Organization / Institution Affiliation*

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Email Address*

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Phone Number*

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Address*

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Category Applied For

Category of Membership*

Refer to Section 4 (Composition) of the ECRB Constitution.

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Qualifications & Eligibility

Highest Qualification*

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Field of Specialization*

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Years of Relevant Experience*

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Eligibility Declarations*

Please confirm each of the following:

I declare that I have no conflicts of interest that would compromise my impartiality on any study likely to be reviewed by this ECRRB

I have no undisclosed financial, professional, or personal conflict of interest

I agree to recuse myself from review of any proposal where a conflict of interest arises

Please confirm all three declarations.

Brief Summary of Relevant Experience*

Describe your experience in research, ethics review, clinical practice, law, social work, or community engagement as relevant to the category applied for.

This field is required.

Research Contribution — Scopus

Scopus Author ID

Found on your Scopus author profile URL, e.g. scopus.com/authid/detail.uri?authorId=XXXXXXXXX

Scopus Profile Link

Total Publications Indexed in Scopus

Scopus H-index

Upload CV / Resume*

PDF or DOC, max 10MB.

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Please upload your CV / Resume.

Upload Scopus Publication List / Export

CSV or PDF, max 10MB.

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Upload Representative Research Papers

Up to 3 PDF files, max 10MB each.

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Training

Have you completed Good Clinical Practice (GCP) / Research Ethics training?*

Yes

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Upload Training Certificate (if applicable)

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Declaration

Declaration*

I agree to maintain confidentiality of all protocols, participant data, and Committee deliberations as required under the ECRRB Constitution

I agree to disclose any conflict of interest at the earliest opportunity

I confirm that the information provided above is true and accurate to the best of my knowledge

Please confirm all three items.

Digital Signature (Full Name)*

Please type your full name as signature.

Date of Application*

Please select a date.