Reg/January/2018/17104/1702202302/53/NBE Print Dated: 18-05-2018

APPLICATION FORM - REGISTRATION AS (DNB Post Diploma) TRAINEE - JANUARY 2018 ADMISSION SESSION

(To be Retained by the candidate for future reference)

DNB Seat Allotment Details:

Merit Position Roll Number Date of Joining Allotted Seat Category
53 1702202302 23.04.2018 UR
Specialty Name DNBTraining Institute/Hospital Name
ENT J.L.N. Main Hosp. & Res. Centre
Bhilai Steel Plant,
BHILAI-01
Chhatisgarh
Personal Details: Scanned Photograph and Sign
Candidate Name Father's/Husband's Name Mother's Name
KAMBAMPATI SATYA SIVA KAMBAMPATI VENKATA KAMBAMPATI DEVI
KUMAR RAMANA
Gender Date of Birth(DD.MM.YYYY) Category
Male 09.03.1987 General

Contact Details:
Primary Mobile Number Secondary Mobile Number E-mail Address
9966886645 9566513777 942603@gmail.com

Permanent Address Correspondence Address

ABOVE APGVB BANK 2ND FLOOR, NEAR ABOVE APGVB BANK 2ND FLOOR, NEAR
LAKSHMI(SVC) THEATRE, MAINROAD LAKSHMI(SVC) THEATRE, MAINROAD
PAYAKARAOPETA, Payakaraopeta, Andhra PAYAKARAOPETA, Payakaraopeta, Andhra
Pradesh, 531126 Pradesh, 531126
Registration Fee Details:
Amount Transcation ID Date of Deposit Name of Bank Name of Branch Branch Code
3000 6063975 09.05.2018 Indian Bank BHILAI SECTOR SIX 00B048

Medical Education and Qualification Details

MCI/SMC Registration:
Registration Number Name of Medical Council State Date of Registration
APMC/FMR/77489 ANDHRA PRADESH MEDICAL ANDHRA PRADESH 25.08.2012
COUNCIL
MBBS Passing Details:
Admission Name of College/Institute Name of University State Passing
Session/Year Month/Year
03.2005 HEBEI MEDICAL COLLEGE HEBEI MEDICAL UNIVERSITY CHINA 03.2010

PG Diploma in: OTO RHINO LARYNGOLOGY

Admission Name of College/Institute Name of University State Passing
Session/Year Month/Year
05.2014 ASRAM MEDICAL COLLEGE DR NTR UNIVERSITY OF ANDHRA 05.2016
HEALTH SCIENCES PRADESH

Thesis Details:
Name of Guide: DR R R BARLE Designation of Guide: MS ENT
Thesis Topic:(Protocol is to be CLINICOPATHOLOGICAL STUDY OF CERVICAL LYMPHADENOPATHY
submitted within 3 months of
Joining the Institution)

***End of Online Filledup Application Form***

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 Reg/January/2018/17104/1702202302/53/NBE Print Dated: 18-05-2018

ACKNOWLEDGEMENT SLIP FOR REGISTRATION AS (DNB Post Diploma) TRAINEE - JANUARY 2018 ADMISSION SESSION
(To be Uploaded on NBE website after duly signed and attested by HOI)
DNB Seat Allotment Details:
Merit Position Roll Number Date of Joining Allotted Seat Category
53 1702202302 23.04.2018 UR
Specialty Name Candidate Name
ENT KAMBAMPATI SATYA SIVA KUMAR

DNB Training Institute/Hospital Name: J.L.N. Main Hosp. & Res. Centre
Bhilai Steel Plant,
BHILAI-01
Chhatisgarh
Contact Details:
Primary Mobile Number Secondary Mobile Number E-mail Address
9966886645 9566513777 942603@gmail.com

Registration Fee Details:

Amount Transcation ID Date of Deposit Name of Bank Branch Code
3000 6063975 09.05.2018 Indian Bank 00B048

Name of Branch: BHILAI SECTOR SIX

MCI/SMC Registration Number Name of Medical Council State Date of Registration

APMC/FMR/77489 ANDHRA PRADESH MEDICAL COUNCIL ANDHRA PRADESH 25.08.2012

Thesis Details:
Name of Guide: DR R R BARLE Designation of Guide: MS ENT
Thesis Topic:(Protocol is to be CLINICOPATHOLOGICAL STUDY OF CERVICAL LYMPHADENOPATHY
submitted within 3 months of
Joining the Institution)

DECLARATION AND CERTIFICATION

I hereby declare and certify that:
a. I have read the general instructions and the rules and regulations of NBE Information Bulletin for DNB Post Diploma and Handbook
for DNB Post Diploma Centralized Counseling - January 2018 admission session and shall abide by them.
b. Particulars given in the application form submitted online are true and accurate to the best of my knowledge and belief.
c. The documents submitted as evidence of above facts herein and at the time of NBE Centralized counseling are true copies of
original documents which belong to me.
d. I understand that in case any of the facts stated by me is/are found to be false or any of the documents enclosed/furnished by me
is/are found to be false, I am liable to be disqualified as registered DNB Trainee/Candidate for DNB programme or any other
appropriate action deemed fit by NBE can be taken against me.
e. I understand that I am eligible as per instructions given in Information Bulletin for DNB Post Diploma - January 2018, however, NBE
reserves the right to determine final eligibility, NBE further reserves the right to cancel the candidature if ineligibility found at any
stage.
Name of the Candidate: Dr. KAMBAMPATI SATYA SIVA KUMAR
Dated:______________

Place:______________ Signature of the Candidate

CERTIFICATE FROM THE HEAD OF THE INSTITUTE

I certify that to the best of my knowledge and belief the statements made above by Dr. KAMBAMPATI SATYA SIVA KUMAR are correct.

Dated:______________ STAMP OF THE INSTITUTION

Place:______________
Signature of Head of the Institute

______________________________________
Name of Head of the Institute
NOTE: PLEASE UPLOAD THIS ACKNOWLEDGEMENT SLIP DULY SIGNED & ATTESTED BY HOI ON NBE WEBSITE AT www.cns.natboard.edu.in.

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