SUBJECT : FAMILY MEDICINE

Transcription

1 SADHU VASWANI MISSION S MEDICAL COMPLEX INLAKS & BUDHRANI HOSPITAL & MORBAI NARAINDAS BUDHRANI CANCER INSTITUTE 7-9 KOREGAON PARK, PUNE APPLICATION FORM FOR DNB REGISTRATION SUBJECT FAMILY MEDICINE (JANUARY, 2011 SESSION) LAST DATE OF SUBMISSION OF APPLICATION FORMS 19 th January, 2011 COLOURED PHOTOGRAPH 35 mm x 35 mm DATE OF INTERVIEW & APPTITUDE TEST 27 th January, 2011 TIME OF INTERVIEW 2.00 p.m. 1. Surname (Block Letters) 2. Name 3. Sex Male / Female 4. Date of Birth 5. Place of Birth 6. Marital Status 7. Father s Name & Occupation 8. Details of Examination Passed Examination Month/Year Attempt Institution University First M.B.B.S Second M.B.B.S 1

2 Third M.B.B.S 9. Details of Third or Final M.B.B.S Medicine Surgery Obstetrics& Gynaec Prev. & Soc. Medicine If Separate Paediatrics E.N.T Ophthalmology Orthopaedics Any Other Month / Year Attempt Marks Obtained % of Marks TOTAL MARKS OBTAINED WITH % 10. Details of Second M.B.B.S Month / Year Attempt Marks Obtained % of Marks Pathology Microbiology Any Other 11. Date of Completion of Internship 12. Indian Medical Council / State Medical Council Permanent Registration No. & Date 2

3 13. Details of Other PG Examination Passed Examination University Year of Passing Marks in Subject Concerned Attempt 14. Experience Appointment From To Institute 15. Whether Registered for Post Graduate Course Degree / Diploma with subject course Registration No. with Date Name of the University or Governing Body Likely date of appearing for Examination 16. Academic Achievement (a) Publications if any (b) Conference Attended (c) CME Attended Note Please attach details with proof 3

4 17. Applicants Postal address in full with telephone No. if any Address (Temporary) Address (Permanent) Phone No. Phone No. Mobile No. Mobile No I have read the Rules and Regulations for DNB Registration of the Inlaks and Budhrani Hospital & Morbai Naraindas Budhrani Cancer Institute, Pune and hereby give an undertaking to abide by the same. Place Date SIGNATURE OF THE APPLICANT Attested Copies of following Certificates must be attached (Attestation should be from Notary Public / Gazetted Officer) 1 MBBS Passing & Degree Certificate. 2 Marksheet of I, II & III year MBBS. 3 Internship Completion Certificate. 4 Attempt Certificate Subjectwise from the college authorities 5 Age Proof (Birth Certificate / SSC Passing Certificate). 6 Registration Certificate with Medical Council. 7 Attach proof of Academic Achievements (Publications, Conference & CME attended). INSTRUCTION FOR PAYMENT TO BE DONE FOR APPLICATION FORM 1. Charges for Application Form is Rs. 750/- per form. 2. Demand Draft of Rs. 750/- should be obtained in name of INLAKS & BUDHRANI HOSPITAL, payable at Pune. 3. Core Banking In case of Core Banking money can be deposited in any branch of State Bank of India where core banking facility is available. The amount should be deposited 4

5 in the name of INLAKS & BUDHRANI HOSPITAL. The Savings Account No. For Core Banking is In case of Core Banking Pay-in slip should be attached with the Application form. 4. Internet Banking In case of Internet Banking the Transaction No. Should be mentioned in the Application Form. The IFS code for Internet Banking is SBIN IMP. NOTE Form without copy of receipted Pay-in Slip in case of Core Banking and Transaction No. in case of Internet Banking will stand rejected. ====================================================================== FOR OFFICE USE ONLY Received Rs. 40,000/- by Cash / Demand Draft No dated vide Receipt No... dated towards Training Fee for the period February, 2011 to January,