- Name (in full)
(Use Block Letters)
|
:
___________________________ |
- Complete address with PIN code to which communications to be sent (Any change to
address should be promptly intimated to the College Office)
|
:
___________________________ |
- Sex
|
: Male
Female
|
- Date of birth
|
: ___________________________ |
- Place of Birth, District and State
|
: Pl.Birth: ___________________________
District: ___________________________
State:
___________________________
|
- Nationality
|
: ___________________________ |
- Educational Qualification
|
: ___________________________ |
- College(s) in which studied
|
:
___________________________ |
- Years Studies
|
:
___________ |
- University which granted the Degree / Diploma
|
: Degree:
Diploma:
|
- Year of Admission to MBBS
|
: ___________ |
- Compulsory Rotatory Resident Internship Period
|
:
___________ |
- Medical Council permanent Registration Certificate No. & Date / Place / State
(Copy to be enclosed)
|
Registration
Certificate No.
___________ Date:
___________
Place:
___________
State:
___________ |
- Experience
|
:
__________________________ |
- Any Post-Graduate qualifications
|
:
__________________________ |
- Any special training undergone
|
:
__________________________ |
- Membership in Professional Societies
|
:
__________________________ |
- Name, address and Tel. No. of relative / any person to be contacted in case of an
emergency
|
:
__________________________ |
( The
following questions are for statistical purpose only - Answers Optional ) |
- Language Known
|
:
__________________________ |
- Religion
|
:
__________________________ |
- Community
|
:
__________________________ |
- Mention your blood group
|
:
__________________________ |
:
- Your Special Hobby
|
:
__________________________ |
Check
List of Documents Enclosed
(Xerox copy of certificates duly attested by and enclosed)
|
Degree Certificate
UG / PG
|
: _______
|
: Registration Certificate
UG / PG
|
: _______ |
Station : _______________ |
|
|
Signature of the
Candidate
|
Careers
