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Pending Approval Christian Medical College, Vellore - 632002.

Online Application form - 2020
Medical Post-Doctoral Fellowship Courses 20022200911
1. Name of the Candidate : BHARATH J
2. Father's Name : JAYARAM K L
3. Mother's Name : KRISHNAVENI P S
Address for communication
4. House No./Street Name : FLAT J, AURO DREAM APARTMENT, FRANCIS
MARTIN STREET
5. Post office/ Taluk name : KURUCHIKUPPAM
6. City Name : PUDUCHERRY
7. State name : PUDUCHERRY
8. Pin Code : 605012
9. Landline No. (With STD Code) :
10. Mobile No. : 9686334646
Only Candidate's Signature Acceptable
11. E Mail Address : drbharathj16@gmail.com
12. Date of Birth : 16/05/1992
13. Gender : Male
14. Religion : Hindu
15. Community : Backward Class
16. Nationality : Indian
I declare that all information in this form is correct.I understand that
17. State of Domicile : Karnataka falsification of data will result in automatic disqualification.I hereby
declare that I have read the rules & regulations regarding raggingas
18. Marital status : Single given in the Prospectus 2020-2021 and agree to abide by the same.
19. Mother Tongue : Kannada
20. Course(s) applied for in order of your preference
:
Medical Post-Doctoral Fellowship Courses - Total Fee Rs. 1000
Pref Course Code - Course Name Applying under Minority Network Category (Y/N)
First F57-NEURO & VASCULAR INTERVENTIONAL RADIOLOGY No
Second F56-CROSS SECTIONAL IMAGING No

21. Details of Academic training

No. Course College Name Date of Date of If previously completed a Duration (Expected) Date
joining completion course under Minority Of Of completion Of
Network Category, choose obligation Service
the organisation in years obligation
1 MBBS/BDS OTHERS MYRSORE MEDICAL 10/08/2009 01/12/2014 -
COLLEGE AND RESE
2 INTERN OTHERS MYRSORE MEDICAL 18/03/2015 17/03/2016 -
COLLEGE AND RESE
3 M.D. IN OTHERS JAWAHARLAL 01/07/2017 30/06/2020 -
RADIODIAGNOSIS INSTITUTE OF POSTGRAD
4

22. Work experience (if any) at CMC Vellore (excluding Internship and Service obligation period for MBBS, Diploma & MD/MS)
No Emp No Designation Appointing authority Appointment from Appointment to Mnths of service
1
2
3
4
5

23. Service in needy area (if any) [excluding internship, service obligation period for MBBS, Diploma & MD/MS/DNB/MDS & work experience in CMC Vellore as filled in the table above]
No Name of Hospitals / Centres Date of Joining Date of Completion Period in Months
1
2
3
4
5

24. City for Entrance Test : First Choice - Puducherry Second Choice - Chennai
25. Have you fulfilled all the eligibility requirements as detailed in the bulletin (Y/N) : Yes
Payment Mode : HDFC Total Application Fee : Rs.1000
HDFC Ref. No: 20200222O0930908 Bank Transid: 202005359073994 Authentication Id: 066580 Status: Yes Online Amount: Rs..1000