APPLICATION FOR PREVEST CLINICAL RESEARCH AWARD   Information for Applicants PRI strongly suggests that the applicant and her/his mentor use the evaluation form to perform a self-evaluation of the case report prior to submitting it for review. Comments on commonly identified problems are included as examples below; however, this is not an all-inclusive list of problems identified in case reports by the peer reveiw Committee. Primary Applicant Applicant Name Tile First Name Surname Mr. Mrs. Ms. Dr.   Qualification   Practice Type   Institution (If Applicable) Department (If Applicable) Street Address     City State Pincode         E-Mail Id     Contact Nos. Phone(Work) Phone(Home) Mobile         Please Indicate if this applicant is in one of the following categories: Private Practitioner Senior Researcher Postgraduate Student Undergraduate Student If Student, Name of the Research Supervisor Is administration of the grant And correspondence the responsibility of this Applicant? No     Yes Dental Discipline   Case Report Title   Date of Publication (Date Format:DD-MM-YYYY)     Name of the Journal   Pubmed Indexing   Impact Factor   Browse Copy of the Publication    (Only jpg or doc or docx or pdf File Formats)