Application Form

Full Name (required)

Address (required)

Pin Code

Telephone

Your Email (required)

Passed MBBS from which Medical College

Complete Internship (dd/mm/yy)

Medical Council Registration State/MCI

Percentage of total Marks or Grade obtained in 1st professional exam (Anatomy, Physiology & Biochemistry together)

Percentage of total Marks or Grade obtained in 2nd professional exam (Pharmacology, pathology, PSM, FSM together)

Percentage of total Marks or Grade obtained in 3rd professional exam (Medicine, Surgery (and allied), Obs & Gyn & Paediatrics together)

Did you pass all subjects on First Attempt: Yes/No:

If no, mention subjects and attempts

A. At present working at (hospital/clinic name)

B. Working as (post)

C. Mention with year about your past engagements since you have completed your internship

D. Mention the course you want to join

E. Want to pursue DGO/DCH from which study Center (give three choices)

Any other choice of City/Hospital

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