Fmge Screening Test Forms

NATIONAL BOARD OF EXAMINATIONS (Ministry of Health & Family Welfare, Govt of India)

NAMS BUILDING, ANSARI NAGAR, MAHATMA GANDHI MARG, NEW DELHI-110029

SCANNABLE

APPLICATION FORM FOR SCREENING TEST (FMGE) SEPTEMBER 2007

To be filled by Indian nationals with foreign primary medical qualification for submission to the National Board of Examinations, Ansari Nagar, New Delhi-110029 on their return to India for appearing in the Screening Test for the purpose of their registration.

Application Form No.

(To be filled by National Board of Examinations Office)

Roll Number

ID Number

DL TO BE FILLED IN CAPITAL LETTERS ONLY

1. Name (CAPITAL LETTERS) (Leave a blank space between first, middle & last names)

2. Father’s/Husband’s Name

3. Mother’s Name

4. Correspondence Address

5. Sex

6. Date of Birth

Male Name

:

Address: ○

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D

D

M

M

PE

E

Y

Y

Y

Y

NE

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1 9

Female

○

○

FOR

○

SE CE U

Y ONL

I

OFF

Pin Code : 7. STD Code

Telephone No./Mobile No.

8. E-mail (Write in Bold & Clear manner)

9.

Photograph 1. Paste here (do not pin or staple) a recent passport size colour photograph as per “INSTRUCTIONS FOR PHOTOGRAPHS” on the inner side of back cover of the Prospectus. 2. The photograph should NOT exceed this box. 3. The photograph to be affixed here should NOT be attested. 4. If the photograph is not clear, the application will be rejected.

10. Nationality i) By Birth/By Domicile ii) Passport No.

iii) Date of Issue

iv) Date upto which valid

D

D

M

M

Y

v) Place of Issue

Y

Y

D

D

M

M

Y

Y

Y

Y

Y

11. Details of previous/lost passport, if any: ii) Previous Passport No.

i) Reason for change of passport 12. Signature of the Candidate (within the box)

iv) Date & Place of Issue iii) FIR No. in respect of lost passport iv) Date of Expiry 13. Percentage of marks of Qualifying Examination passed: English Physics Chemistry

14. Medical Course : Joined on

D

D

M

M

Y

Y

Y

Biology

Grand Total

15. Have you been granted Provisional Registration by MCI or any State Medical Council: Date If yes, Please give details of: Registration No.

D

Name of Council D

D

M

M

Y

Y

Y

* Form Fee (*For downloaded form only)

D

M

M

Y

Y

Y

Y

Y

(Please mark (X) in the appropriate box)

Examination Fee

No

Y

Completed on

16. Examination Fee

Yes

Rs. 3000

Bank Draft No.

CANDIDATE TO ENSURE THAT THE FEES IS PAID BY SINGLE DRAFT ONLY Amount Dated

2

Rs. 500 Name of the Bank

D

D

M

M

Y

0

0

7

Y

Y

Y

P.T.O.

17. Details of the qualifying Examination passed Name of the Examination passed (10+2) OR equivalent): Subjects i)

Maximum Marks

Marks Obtained

%age Board Name & Address

English

ii) Physics Month & Year of Passing

iii) Chemistry iv) Biology

M

M

Y

Y

Y

Y

v) GRAND TOTAL Name of the Institution with Address

18. If done B.Sc., Please give details of examination passed: Subject/Marks/Roll No. & Year of passing / name of the university etc.

19. Details of Primary Medical Qualification Year

Name of Medical Institution / University

Registration No. (with city & country)

Valid from

Address of the Registering Authority

Valid upto

Preparatory Course (if any) 1st Year 2nd Year 3rd Year 4th Year 5th Year 6th Year 20. Whether the Medical Institute (s) indicated in S. No. 18 above is/are recognised in the country in which they are situated for award of the primary medical qualification.

Yes

No

21. Internship done in the foreign country a) Duration

b)

c) 3 months rural training compulsory Yes

Rotatory/Otherwise

d) Periods when internship done from

To

No D

D

M

M

Y

Y

Y

Y

D

D

M

M

Y

Y

Y

Y

e) Place (s) where done

f) Whether the institution where Internship was done, is recognised by the foreign medical Council/ Medical Council of India 22. Were you ever deported / rusticated during medical course

Yes

No

23. Whether obtained Eligibility Certificate from MCI

Yes

No

Yes

No

DECLARATION I here by declare & certify that: a)

I am an Indian Citizen,

b)

Particulars given in this application form are true and accurate to the best of my knowledge and belief.

c)

The documents submitted as evidence of above facts are original / attested photocopy of original documents.

d)

I understand that in case any of the fact stated by me are found to be false or any of the documents enclosed by me are found to be fake, I am liable to be disqualified from appearing in the Screening Test or registration, if granted, shall be liable to be revoked.

Place:

Date: _______________

Signature of the Candidate

NATIONAL BOARD OF EXAMINATIONS (Ministry of Health & Family Welfare, Govt of India)

NAMS BUILDING, ANSARI NAGAR, MAHATMA GANDHI MARG, NEW DELHI-110029

NON-SCANNABLE

APPLICATION FORM FOR SCREENING TEST (FMGE) SEPTEMBER 2007

To be filled by Indian nationals with foreign primary medical qualification for submission to the National Board of Examinations, Ansari Nagar, New Delhi-110029 on their return to India for appearing in the Screening Test for the purpose of their registration.

Application Form No.

(To be filled by National Board of Examinations Office)

Roll Number

ID Number

DL TO BE FILLED IN CAPITAL LETTERS ONLY

1. Name (CAPITAL LETTERS) (Leave a blank space between first, middle & last names)

2. Father’s/Husband’s Name

3. Mother’s Name

4. Correspondence Address

5. Sex

6. Date of Birth

Male Name

:

Address: ○

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○

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State :

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D

D

M

M

PE

E

Y

Y

Y

Y

NE

○

○

○

1 9

Female

○

○

FOR

○

SE CE U

Y ONL

I

OFF

Pin Code : 7. STD Code

Telephone No./Mobile No.

8. E-mail (Write in Bold & Clear manner)

9.

Photograph 1. Paste here (do not pin or staple) a recent passport size colour photograph as per “INSTRUCTIONS FOR PHOTOGRAPHS” on the inner side of back cover of the Prospectus. 2. The photograph should NOT exceed this box. 3. The photograph to be affixed here should be attested. 4. If the photograph is not clear, the application will be rejected.

10. Nationality i) By Birth/By Domicile ii) Passport No.

iii) Date of Issue

iv) Date upto which valid

D

D

M

M

Y

v) Place of Issue

Y

Y

D

D

M

M

Y

Y

Y

Y

Y

11. Details of previous/lost passport, if any: ii) Previous Passport No.

i)

Reason for change of passport 12. Signature of the Candidate (within the box)

iv) Date & Place of Issue iii) FIR No. in respect of lost passport iv) Date of Expiry 13. Percentage of marks of Qualifying Examination passed: English Physics Chemistry

14. Medical Course : Joined on

D

D

M

M

Y

Y

Y

Biology

Grand Total

15. Have you been granted Provisional Registration by MCI or any Please State Medical Council: Date If yes, give details of: Registration No.

D

Name of Council D

D

M

M

Y

Y

Y

* Form Fee (*For downloaded form only)

D

M

M

Y

Y

Y

Y

Y

(Please mark (X) in the appropriate box)

Examination Fee

No

Y

Completed on

16. Examination Fee

Yes

Rs. 3000

Bank Draft No.

CANDIDATE TO ENSURE THAT THE FEES IS PAID BY SINGLE DRAFT ONLY Amount Dated

2

Rs. 500 Name of the Bank

D

D

M

M

Y

0

0

7

Y

Y

Y

P.T.O.

17. Details of the qualifying Examination passed Name of the Examination passed (10+2) OR equivalent): Subjects i)

English

ii)

Physics

iii)

Chemistry

iv)

Biology

Maximum Marks

Marks Obtained

%age Board Name & Address

Month & Year of Passing

M

M

Y

Y

Y

Y

v) GRAND TOTAL Name of the Institution with Address

18. If done B.Sc., Please give details of examination passed: Subject/Marks/Roll No. & Year of passing / name of the university etc.

19. Details of Primary Medical Qualification Year

Name of Medical Institution / University

Registration No. (with city & country)

Valid from

Address of the Registering Authority

Valid upto

Preparatory Course (if any) 1st Year 2nd Year 3rd Year 4th Year 5th Year 6th Year 20. Whether the Medical Institute (s) indicated in S. No. 18 above is/are recognised in the country in which they are situated for award of the primary medical qualification.

Yes

No

21. Internship done in the foreign country a)

Duration

b)

c) 3 months rural training compulsory Yes

Rotatory/Otherwise

d) Periods when internship done from

To

No D

D

M

M

Y

Y

Y

Y

D

D

M

M

Y

Y

Y

Y

e) Place (s) where done

f) Whether the institution where Internship was done, is recognised by the foreign medical Council/ Medical Council of India 22. Were you ever deported / rusticated during medical course

Yes

No

23. Whether obtained Eligibility Certificate from MCI

Yes

No

Yes

No

DECLARATION I here by declare & certify that: a)

I am an Indian Citizen,

b)

Particulars given in this application form are true and accurate to the best of my knowledge and belief.

c)

The documents submitted as evidence of above facts are original / attested photocopy of original documents.

d)

I understand that in case any of the fact stated by me are found to be false or any of the documents enclosed by me are found to be fake, I am liable to be disqualified from appearing in the Screening Test or registration, if granted, shall be liable to be revoked.

Place:

Date: _______________

Signature of the Candidate

NATIONAL BOARD OF EXAMINATIONS (Ministry of Health & Family Welfare, Govt of India)

NAMS BUILDING, ANSARI NAGAR, MAHATMA GANDHI MARG, NEW DELHI-110029

APPLICATION FORM FOR SCREENING TEST (FMGE) SEPTEMBER 2007 To be filled by Indian nationals with foreign primary medical qualification for submission to the National Board of Examinations, Ansari Nagar, New Delhi-110029 on their return to India for appearing in the Screening Test for the purpose of their registration.

Application Form No.

(To be filled by National Board of Examinations Office)

Roll Number

ID Number

TO BE FILLED IN CAPITAL LETTERS ONLY

1. Name (CAPITAL LETTERS) (Leave a blank space between first, middle & last names)

2. Father’s/Husband’s Name

3. Mother’s Name

4. Correspondence Address

6. Date of Birth

Male Name

:

Address: ○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

State :

○

○

○

○

○

○

○

○

○

○

○

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City :

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C

ii) Passport No.

D

D

M

M

Y

Y

Y

E

11. Details of previous/lost passport, if any: ii) Previous Passport No.

P

i)

M

M

PE

1 9 Y

Y

Y

Y

NE

SE CE U

Y ONL

9.

Photograph

iii) Date of Issue

v) Place of Issue

Y

D

I

OFF

8. E-mail (Write in Bold & Clear manner)

10. Nationality i) By Birth/By Domicile

iv) Date upto which valid

M

FOR

○

I

Telephone No./Mobile No.

E

E

○

○

○

Female D

Pin Code : 7. STD Code

N

5. Sex

D

D

M

M

Y

Y

Y

Y

Reason for change of passport 12. Signature of the Candidate (within the box)

iv) Date & Place of Issue

iii) FIR No. in respect of lost passport iv) Date of Expiry

S

13. Percentage of marks of Qualifying Examination passed: English Physics Chemistry

14. Medical Course : Joined on

D

D

M

M

Y

Y

Y

Biology

Grand Total

15. Have you been granted Provisional Registration by MCI or any Please State Medical Council: Date If yes, give details of: Registration No.

D

Name of Council D

D

M

M

Y

Y

Y

* Form Fee (*For downloaded form only)

D

M

M

Y

Y

Y

Y

Y

(Please mark (X) in the appropriate box)

Examination Fee

No

Y

Completed on

16. Examination Fee

Yes

Rs. 3000

Bank Draft No.

CANDIDATE TO ENSURE THAT THE FEES IS PAID BY SINGLE DRAFT ONLY Amount Dated

2

Rs. 500 Name of the Bank

D

D

M

M

Y

0

0

7

Y

Y

Y

P.T.O.

17. Details of the qualifying Examination passed Name of the Examination passed (10+2) OR equivalent): Subjects i)

English

ii)

Physics

iii)

Chemistry

iv)

Biology

Maximum Marks

Marks Obtained

%age Board Name & Address

Month & Year of Passing

M

M

Y

Y

Y

Y

v) GRAND TOTAL Name of the Institution with Address

18. If done B.Sc., Please give details of examination passed: Subject/Marks/Roll No. & Year of passing / name of the university etc.

19. Details of Primary Medical Qualification Year

Name of Medical Institution / University

Registration No. (with city & country)

Valid from

Address of the Registering Authority

Valid upto

Preparatory Course (if any) 1st Year 2nd Year 3rd Year 4th Year 5th Year 6th Year 20. Whether the Medical Institute (s) indicated in S. No. 18 above is/are recognised in the country in which they are situated for award of the primary medical qualification.

Yes

No

21. Internship done in the foreign country a)

Duration

b)

c) 3 months rural training compulsory Yes

Rotatory/Otherwise

d) Periods when internship done from

To

No D

D

M

M

Y

Y

Y

Y

D

D

M

M

Y

Y

Y

Y

e) Place (s) where done

f) Whether the institution where Internship was done, is recognised by the foreign medical Council/ Medical Council of India 22. Were you ever deported / rusticated during medical course

Yes

No

23. Whether obtained Eligibility Certificate from MCI

Yes

No

Yes

No

DECLARATION I here by declare & certify that: a)

I am an Indian Citizen,

b)

Particulars given in this application form are true and accurate to the best of my knowledge and belief.

c)

The documents submitted as evidence of above facts are original / attested photocopy of original documents.

d)

I understand that in case any of the fact stated by me are found to be false or any of the documents enclosed by me are found to be fake, I am liable to be disqualified from appearing in the Screening Test or registration, if granted, shall be liable to be revoked.

Place:

Date: _______________

Signature of the Candidate