Professional Documents
Culture Documents
Fmge Scannable Sept 2010
Fmge Scannable Sept 2010
DL
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
D D M M Y Y Y Y
Address: ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
E PE NE
State : ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
8. Country / STD Code Telephone No./Mobile No.
Pin Code :
(See Annexure-5B for Country Code)
12. Have you been granted Provisional Registrationby MCI 13. Signature of the Candidate
Yes No (within the box)
or any State Medical Council:
If yes, Please give details of: Registration No. Date
Name of Council D D M M Y Y Y Y
14. Whether Degree has been awarded by the Foreign Medical Institute: Yes No
15. Medical Course : Joined on
Whether Eligibility Certificate received from MCI : Yes No
Code: Name:
D D M M Y Y Y Y
(TO BE FILLED IN CAPITAL LETTERS)
17. Detaills of latest session of FMG Examination appeared Previous Roll No. Session Year
i) Have you appeared previously in FMGE Yes No If Yes,
18. Examination Fee (Please mark (X) in the appropriate box) (Copy of Admit Card to be enclosed)
iii) FIR No. in respect of lost passport iv) Date & Place of Issue iv) Date of Expiry
ii) Physics
iv) Biology
M M Y Y Y Y
GRAND TOTAL
21. If done B.Sc., Please give details of examination passed: Subject/Marks/Roll No. & Year of passing / name of the university etc.
2nd Year
3rd Year
4th Year
5th Year
6th Year
23. Whether the Medical Institute (s) indicated in S. No. 16 above is/are recognised in the country in
Yes No
which they are situated for award of the primary medical qualification.
24. Internship done in the foreign country
a) Duration b) Rotatory/Otherwise
c) 3 months rural training compulsory d) Periods when internship done from To
Yes 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 Yes No
25. Were you ever deported / rusticated during medical course 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 Left Thumb Impression of the Candidate
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.
e) Certified that I, the undersigned candidate have filled this application in my own handwriting.
Place: ___________________________
Date: _______________ Signature of the Candidate Right Thumb Impression of the Candidate