GMC - RACGP - MOH FELLOWSHIP PROGRAM
A. PERSONAL DATA
  Name *:
  Sex *:  
  Date of Birth : / /
  Age as on 31st December of academic Year *:
  Email *:
  Nationality* :
Marital Status :
  Mother Tongue :    
  Language proficiency :    
 
Read :
Write:
Speak:
 
Present Position:*
Address for corresponding :
 
Telephone/Mobile No*.:
Telex / Fax :
  Passport Details :  
 
  Passport Number *:   Date of Issue :
  Date of Expiry:   Issued at :
           
  Student Visa :  
  Hostel Accommodation :  
     
B. ACADEMIC PARTICULARS
Examination Passed
Name & address of the School/College
Name of the University / Board
Reg. No.
No. Of attempts for passing
Year of passing
a. MBBS/M.D
b. Any other higher qualification
c. TOEFL or other English
language proficiency list score
 
C. QUALIFYING EXAMINATION DETAILS
  a. Name of the Examination passed* :
  b. Name and Address of the Institution* :
  c. University / Board to which attached*:
  d. Total marks secured in all subjects *: out of (maximum):
  Percentage:
Professional work experience details:
Period of Employment/Training
Name of Hospital/Unit
Areas of Expertise/Training

( mm/dd/yyyy)

( mm/dd/yyyy)

( mm/dd/yyyy)
 
D. DECLARATION BY STUDENT
  I have carefully read the instructions given in the prospects and agree to abide by the decision of the Institute's authorities regarding my selection for the programme. I certify that the particulars given by me in this application form are true to the best of my knowledge and belief
  Place :
  Date : Signature of the applicant
  NOTE :INCOMPLETE APPLICATION FORM WILL NOT BE ACCEPTED