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NATIONAL BOARD OF EXAMINATIONS
(Ministry of Health & Family Welfare, Govt of India)
12. Signature of the Candidate
(within the box)
   ○○○○○○○○○○○○      ○○○○○○○○○○○○○○○○○○○○○○○○○○○   
Pin Code :
   ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○   
Name :Address:
   ○○○○○○○○○○○○○○○○○○○○○○○○○○○      ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○   
Application Form No.
2.Father’s/Husband’s Name1.Name (CAPITAL LETTERS)
(Leave a blank space between first, middle & last names)City :
   ○○○○○○○○○○○○○○○○   
State :
Roll Number
4.Correspondence Address5.Sex6.Date of Birth
D DM MY Y Y Y
7.STD CodeTelephone No./Mobile No.8.E-mail
(Write in Bold & Clear manner)
9.
NAMS BUILDING, ANSARI NAGAR, MAHATMA GANDHI MARG, NEW DELHI-110029
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.
ID Number
(To be filled by National Board of Examinations Office)
TO BE FILLED IN CAPITAL LETTERS ONLY
MaleFemale
10.Nationalityi)By Birth/By Domicileii)Passport No.iii)Date of Issue
D DM MY Y Y Y
v)Place of Issueiv)Date upto which valid
D DM MY Y Y Y
13.Percentage of marks of Qualifying Examination passed:English14.Medical Course : Joined on
D DM MY Y Y Y
15.Have you been grantedProvisional Registration by MCIor any State Medical Council:
YesNo
Completed on
D DM MY Y Y Y
If yes, Please give details of: Registration No.Name of CouncilDate
D DM MY Y Y Y
P.T.O.
19
Photograph
1.Paste here (do not pin or staple)a recent passport size colourphotograph as per
“INSTRUCTIONS FORPHOTOGRAPHS”
 on the innerside of back cover of theProspectus.2. The photograph should 
NOT
exceed this box.3. The photograph to be affixed hereshould 
NOT
 be attested.4.If the photograph is not clear,the application will be rejected.D DM MY Y Y Y
16.Examination Fee
(Please mark (X) in the appropriate box)Examination FeeRs. 3000*Form FeeRs. 500Bank Draft No.DatedName of the BankAmount
(*For downloaded form only)
CANDIDATE TO ENSURE THAT THE FEES IS PAID BY SINGLE DRAFT ONLY
 F O R  O F F I C E  U S E  O N L Y
EPE NE
SCANNABLEAPPLICATION FORM FOR SCREENING TEST (FMGE) SEPTEMBER 2007
PhysicsChemistryBiologyGrand Total11.Details of previous/lost passport, if any: i)Reason for change of passportii)Previous Passport No.iii)FIR No. in respect of lost passportiv)Date & Place of Issueiv)Date of Expiry3.Mother’s Name
2 0 0 7
DL
 
Date: _______________ Signature of the Candidate
19.Details of Primary Medical Qualification
Name of Medical Institution / UniversityRegistration No.(with city & country)Place:
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 liableto be disqualified from appearing in the Screening Test or registration, if granted, shall be liable to be revoked.Subjects Maximum Marks Marks Obtained %agei)Englishii)Physicsiii)Chemistryiv)Biologyv)
GRAND TOTALName of the Institution with Address18.If done B.Sc., Please give details of examination passed: Subject/Marks/Roll No. & Year of passing / name of the university etc.
YearAddress of theRegistering AuthorityValidfromValiduptoPreparatoryCourse (if any)1
st
Year2
nd
Year3
rd
Year4
th
Year5
th
Year6
th
Year
20.Whether the Medical Institute (s) indicated in S. No. 18 above is/are recognised in the country inwhich they are situated for award of the primary medical qualification.
YesNo
21.Internship done in the foreign countrya)Durationb) Rotatory/Otherwised)Periods when internship done fromTo
D DM MY Y Y YD DM MY Y Y Y
c) 3 months rural training compulsory
YesNo
e) Place (s) where donef) Whether the institution where Internship was done, is recognised by the foreign medical Council/Medical Council of India
YesNo
22.Were you ever deported / rusticatedduring medical course
YesNo
23.Whether obtained EligibilityCertificate from MCI
YesNo
17.Details of the qualifying Examination passedName of the Examination passed(10+2) OR equivalent):Board Name & AddressMonth & Year of Passing
Y Y Y YM M
 
NATIONAL BOARD OF EXAMINATIONS
(Ministry of Health & Family Welfare, Govt of India)
12. Signature of the Candidate
(within the box)
   ○○○○○○○○○○○○      ○○○○○○○○○○○○○○○○○○○○○○○○○○○   
Pin Code :
   ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○   
Name :Address:
   ○○○○○○○○○○○○○○○○○○○○○○○○○○○      ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○   
Application Form No.
2.Father’s/Husband’s Name1.Name (CAPITAL LETTERS)
(Leave a blank space between first, middle & last names)City :
   ○○○○○○○○○○○○○○○○   
State :
Roll Number
4.Correspondence Address5.Sex6.Date of Birth
D DM MY Y Y Y
7.STD CodeTelephone No./Mobile No.8.E-mail
(Write in Bold & Clear manner)
9.
NAMS BUILDING, ANSARI NAGAR, MAHATMA GANDHI MARG, NEW DELHI-110029
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.
ID Number
(To be filled by National Board of Examinations Office)
TO BE FILLED IN CAPITAL LETTERS ONLY
MaleFemale
10.Nationalityi)By Birth/By Domicileii)Passport No.iii)Date of Issue
D DM MY Y Y Y
v)Place of Issueiv)Date upto which valid
D DM MY Y Y Y
13.Percentage of marks of Qualifying Examination passed:English14.Medical Course : Joined on
D DM MY Y Y Y
15.Have you been grantedProvisional Registration byMCIor any State Medical Council:
YesNo
Completed on
D DM MY Y Y Y
If yes, Please give details of: Registration No.Name of CouncilDate
D DM MY Y Y Y
P.T.O.
19
Photograph
1.Paste here (do not pin or staple)a recent passport size colourphotograph as per
“INSTRUCTIONS FORPHOTOGRAPHS”
 on the innerside of back cover of theProspectus.2. The photograph should 
NOT
exceed this box.3. The photograph to be affixed hereshould be attested.4.If the photograph is not clear,the application will be rejected.D DM MY Y Y Y
16.Examination Fee
(Please mark (X) in the appropriate box)Examination FeeRs. 3000*Form FeeRs. 500Bank Draft No.DatedName of the BankAmount
(*For downloaded form only)
CANDIDATE TO ENSURE THAT THE FEES IS PAID BY SINGLE DRAFT ONLY
 F O R  O F F I C E  U S E  O N L Y
EPE NE
NON-SCANNABLEAPPLICATION FORM FOR SCREENING TEST (FMGE) SEPTEMBER 2007
PhysicsChemistryBiologyGrand Total11.Details of previous/lost passport, if any: i)Reason for change of passportii)Previous Passport No.iii)FIR No. in respect of lost passportiv)Date & Place of Issueiv)Date of Expiry3.Mother’s Name
2 0 0 7
DL
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