Diploma of National Board Admission Form

Kurji Holy Family Hospital,Patna

P.O - S. Ashram, Patna -800010,Bihar

Subject :

 

Name in Full :                    

                                             Last                               First                              Middle

Father's/Husband's Name:

Permanent Address:           

                                             

                                              District  State

                                              Pin No: 

Correspondence  Address: 

                                             

                                              District State

                                              Pin No:

Date of Birth DD MM YYYY

 

MCI/SMC Reg. No.
Date of Registration DD MM YYYY
State

Details of Examination passed (Attested copies of certificates to be attached):

Examination Passed

Subjects

Name of Medical College

University

State

Year of Passing

% of

Marks

No. of

Attempt

MBBS “ I ”

     N/A

 

 

 

 

 

 

MBBS “ II ”

     N/A

 

 

 

 

 

 

MBBS “ Final”

     N/A

 

 

 

 

 

 

CET-NBE/ Primary

     N/A

 

 

 

 

 

 

P.G. Diploma

 

 

 

 

 

 

 

MD/MS/ DM/Mch

 

 

 

 

 

 

 

Others

 

 

 

 

 

 

 

 Work Experience after MBBS

Post

Department

Name of Hospital

Duration

From                                To

 

 

     

 

 

      

Present Employment:

Marital Status: Single/Married/Widow ( Delete whatever not applicable)

Name of Two Referees and their Address (Preferably Head of the Department under whom  the  candidate worked):  

Name

Correspondence Address

1. 

 

 

 

 2.

 

 

 

         Note :  You have to come for interview with following  Attested copies of certificates :  

(a)    MBBS Degree, Attempt, Character Certificate 

(b)    Medical Council Registration Certificate (State or MCI) – preferably Bihar

(c)    Internship Certificate

(d)   House job Certificate

(e)    MBBS Mark Sheets of  I, II, and Final

(f)     P.G Degree/ Diploma Pass Certificate

(g)    P.G. Diploma training Certificate with date of starting and finishing.                                                                                        

(h)    CET-NBE/Primary Pass Certificate

(i)      High School Certificate for verification of date of Birth.