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. (To be filled by National Board of Examinations Office)

Application Form No.

ID Number

Roll 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 Male
○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

6. Date of Birth Female
D D M M

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

v) Place of Issue
Y Y

D

D

M

M

Y

Y

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

i) Reason for change of passport iv) Date & Place of Issue 12. Signature of the Candidate (within the box)

iv) Date of Expiry 13. Percentage of marks of Qualifying Examination passed: English Physics Chemistry Biology Grand Total

14. Medical Course : Joined on

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

D

D

M

M

Y

Y

Y

Completed on Name of Council
D D M M Y Y Y Y

16. Examination Fee Examination Fee * Form Fee

(Please mark (X) in the appropriate box) Rs. 3000 Rs. 500 Name of the Bank Bank Draft No.

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

(*For downloaded form only)

State :

City :

Address:
○ ○ ○ ○ ○

Name

:

1 9
Y Y Y Y

E

PE

NE

FOR

OFF

I

SE CE U

Y ONL

D

D

M

M

Y

Y

Y

Y

Yes

No

D

D

M

M

Y

Y

Y

Y

2
D D M M Y

0
Y

0
Y

7
Y

P.T.O.

17. Details of the qualifying Examination passed Name of the Examination passed (10+2) OR equivalent): Subjects i) English Maximum Marks Marks Obtained %age Board Name & Address

ii) Physics iii) Chemistry iv) Biology
M M Y Y Y Y

Month & Year of Passing

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 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. 21. Internship done in the foreign country a) Duration c) 3 months rural training compulsory Yes e) Place (s) where done No
D D M M Y Y Y Y D D M M Y Y Y Y

Name of Medical Institution / University

Registration No. (with city & country)

Address of the Registering Authority

Valid from

Valid upto

Yes

No

b)

Rotatory/Otherwise To

d) Periods when internship done from

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 Yes

No No

DECLARATION
I here by declare & certify that: a) b) c) d) I am an Indian Citizen, Particulars given in this application form are true and accurate to the best of my knowledge and belief. The documents submitted as evidence of above facts are original / attested photocopy of original documents. 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. (To be filled by National Board of Examinations Office)

Application Form No.

ID Number

Roll 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 Male
○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

6. Date of Birth Female
D D M M

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

v) Place of Issue
Y Y

D

D

M

M

Y

Y

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

i)

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

iv) Date & Place of Issue

iv) Date of Expiry 13. Percentage of marks of Qualifying Examination passed: English Physics Chemistry Biology Grand Total

14. Medical Course : Joined on

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

D

D

M

M

Y

Y

Y

Completed on Name of Council
D D M M Y Y Y Y

16. Examination Fee Examination Fee * Form Fee

(Please mark (X) in the appropriate box) Rs. 3000 Rs. 500 Name of the Bank Bank Draft No.

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

(*For downloaded form only)

State :

City :

Address:
○ ○ ○ ○ ○

Name

:

1 9
Y Y Y Y

E

PE

NE

FOR

OFF

I

SE CE U

Y ONL

D

D

M

M

Y

Y

Y

Y

Yes

No

D

D

M

M

Y

Y

Y

Y

2
D D M M Y

0
Y

0
Y

7
Y

P.T.O.

17. Details of the qualifying Examination passed Name of the Examination passed (10+2) OR equivalent): Subjects i) ii) iii) iv) v) GRAND TOTAL Name of the Institution with Address English Physics Chemistry Biology
M M Y Y Y Y

Maximum Marks

Marks Obtained

%age Board Name & Address

Month & Year of Passing

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 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. 21. Internship done in the foreign country a) Duration b) Rotatory/Otherwise To Yes No Name of Medical Institution / University Registration No. (with city & country) Address of the Registering Authority Valid from Valid upto

c) 3 months rural training compulsory Yes e) Place (s) where done No

d) Periods when internship done from

D

D

M

M

Y

Y

Y

Y

D

D

M

M

Y

Y

Y

Y

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 Yes

No No

DECLARATION
I here by declare & certify that: a) b) c) d) I am an Indian Citizen, Particulars given in this application form are true and accurate to the best of my knowledge and belief. The documents submitted as evidence of above facts are original / attested photocopy of original documents. 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. (To be filled by National Board of Examinations Office)

Application Form No.

ID Number

Roll Number

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

TO BE FILLED IN CAPITAL LETTERS ONLY

2. Father’s/Husband’s Name

3. Mother’s Name

4. Correspondence Address

5. Sex Male
○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

6. Date of Birth Female

Pin Code :
7. STD Code Telephone No./Mobile No.

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

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

C
Y Y Y

iii) Date of Issue

iv) Date upto which valid

D

D

M

M

Y

E

v) Place of Issue

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

P
Y

i)

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

iv) Date & Place of Issue

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

S
Y Y

iv) Date of Expiry Biology Grand Total

14. Medical Course : Joined on

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

D

D

M

M

Y

Y

Completed on Name of Council
D D M M Y Y Y

16. Examination Fee Examination Fee * Form Fee

(Please mark (X) in the appropriate box) Rs. 3000 Rs. 500 Name of the Bank Bank Draft No.

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

(*For downloaded form only)

State :

City :

Address:
○ ○ ○ ○ ○

Name

:

N
M

1 9
Y Y Y Y

E

E
FOR OFF I

D

D

M

PE

NE

I
D

M
M M Y

SE CE U

Y ONL

9.

Photograph

D

Y

Y

Y

Yes

No

D

D

M

M

Y

Y

Y

Y

2
D D M M Y

0
Y

0
Y

7
Y

P.T.O.

17. Details of the qualifying Examination passed Name of the Examination passed (10+2) OR equivalent): Subjects i) ii) iii) iv) v) GRAND TOTAL Name of the Institution with Address English Physics Chemistry Biology
M M Y Y Y Y

Maximum Marks

Marks Obtained

%age Board Name & Address

Month & Year of Passing

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 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. 21. Internship done in the foreign country a) Duration b) Rotatory/Otherwise To Yes No Name of Medical Institution / University Registration No. (with city & country) Address of the Registering Authority Valid from Valid upto

c) 3 months rural training compulsory Yes e) Place (s) where done No

d) Periods when internship done from

D

D

M

M

Y

Y

Y

Y

D

D

M

M

Y

Y

Y

Y

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 Yes

No No

DECLARATION
I here by declare & certify that: a) b) c) d) I am an Indian Citizen, Particulars given in this application form are true and accurate to the best of my knowledge and belief. The documents submitted as evidence of above facts are original / attested photocopy of original documents. 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