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Sri Ramachandra Medical College & Research Institue
(Deemed University) Porur, Chennai - 600 116


  1. Name (in full)
    (Use Block Letters)
: ___________________________
  1. Complete address with PIN code to which communications to be sent (Any change to address should be promptly intimated to the College Office)
: ___________________________
  1. Sex
Male    Female
  1. Date of birth
: ___________________________
  1. Place of Birth, District and State
: Pl.Birth: ___________________________ District:  ___________________________
  State: ___________________________
  1. Nationality
: ___________________________
  1. Educational Qualification
: ___________________________
  1. College(s) in which studied
: ___________________________
  1. Years Studies
: ___________
  1. University which granted the Degree / Diploma
: Degree:                Diploma:   
  1. Year of Admission to MBBS
: ___________
  1. Compulsory Rotatory Resident Internship Period
: ___________
  1. Medical Council permanent Registration Certificate No. & Date / Place / State (Copy to be enclosed)
Registration Certificate No.  ___________

Date: ___________

Place: ___________

State: ___________

  1. Experience
: __________________________
  1. Any Post-Graduate qualifications
: __________________________
  1. Any special training undergone
: __________________________
  1. Membership in Professional Societies
: __________________________
  1. 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 )

  1. Language Known
: __________________________
  1. Religion
: __________________________
  1. Community
: __________________________
  1. Mention your blood group
: __________________________
:
  1. Your Special Hobby
: __________________________

Check List of Documents Enclosed
(Xerox copy of certificates duly attested by and enclosed)

  1. Degree Certificate                  UG / PG

: _______

  1. : Registration Certificate         UG / PG
: _______

Station : _______________

Date     : _______________

 

Signature of the Candidate

 

Note : Plese take Printout of this form, fill it up and send it.

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