DNB Form
DNB Form
NAMS BUILDING, ANSARI NAGAR, MAHATMA GANDHI MARG, NEW DELHI-110029 SCANNABLE APPLICATION FOR POST DIPLOMA CENTRALISED ENTRANCE TEST (POST DIPLOMA CET) AUGUST 2011 Application Form No.
INSTRUCTIONS :-
* * * * *
INCOMPLETE APPLICATION FORMS WILL NOT BE CONSIDERED. READ PROSPECTUS CAREFULLY BEFORE FILLING UP THE FORM. PLEASE SUBMIT THIS FORM IN ENVELOPE PROVIDED. DO NOT ATTACH ANY ENCLOSURES WITH THIS APPLICATION FORM. USE BLUE/BLACK BALL PEN ONLY
PE
NE
DL
3. Fathers/Husbands Name
4. M others Name
5.b) Dated
6. Gender Male
7. Date of Birth
1 9
D D M M Y Y Y Y
Female
9. Mobile No.
12. Centre preferred for Post diploma CET Examination 1st Choice Code
2nd Choice 13. Examination Fee Examination Fee Form Fee (Please mark (X) in the appropriate box) Rs. 3500 Rs. 750 Challan / ID No. :
D D
Code
Amount : Name of the Bank Branch: NBE Copy of Pay-in-Slip / Challan of Indian Bank should be enclosed. 14. Are you pursuing any MD/MS/DNB Post graduate degree programme. If yes, Name of the course:____________________________. 15. Correspondence Address Name : 16. Signature of the Candidate (within the box) Yes No
Address:
City : State :
Pin Code :
P.T.O.
18. Details of MBBS and Post Graduate Diploma Examination (attested copies of Certificates to be attached)
Examination Passed
Subject
Medical College
University
State
Result
No. of Attempts
1st MBBS
2nd MBBS
Final MBBS
P.G Diploma
1. 2. 3. 4. 5.
Two extra recent passport size photographs duly attested. Self attested photocopy of Permanent Registration Certificate of Medical Council of India /State Medical Council. Self attested photocopy of MBBS Degree Certificate and P.G Diploma. Proof of PG diploma being recognized by MCI IMR Certificate specifying additional qualification/ Additional qualification registration certificate issued by MCI/ printout of MCI website showing recognition status of PG Diploma. NBE Copy of Pay-in-Slip / Challan of Indian Bank / Axis Bank
DECLARATION & CERTIFICATION
I here by declare and certify that: a) I have read the general instructions and the rules and regulations of NBE in Bulletin of Information and shall abide by them. 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 and are self attested photocopy of original documents. d) I understand that in case any of the facts stated by me is/are found to be false or any of the documents enclosed by me is/are found to be false, I am liable to be disqualified from appearing in the Examination and if permission granted for appearing in the examination shall be liable to be revoked or any other appropriate action deemed fit by NBE can be taken against me. e) I understand that I am eligible as per instructions given in Bullettin of Information, however, NBE reserves the right to determine final eligibility;NBE further reserves the right to cancel the candidature if ineligibility found at any stage. f) Candidates Name in Block Letters
Date:
/2011
Date:
Signature of the Head of Institution with Name and office stamp /2011 ( In case, Candidate is not working, the above column may be attested by a Gazetted officer)
NOTE : USE / POSSESSION OF MOBILE PHONE / ELECTRONIC DEVICE IS NOT PERMITED IN EXAMINATION PREMISES AND PHOTOCOPY OF THE FILLED UP APPLICATION FORM MUST BE RETAINED BY THE CANDIDATE FOR FUTURE USE.
* * * *
INCOMPLETE APPLICATION FORMS WILL NOT BE CONSIDERED. READ PROSPECTUS CAREFULLY BEFORE FILLING UP THE FORM. PLEASE SUBMIT THIS FORM IN ENVELOPE PROVIDED. USE BLUE/BLACK BALL PEN ONLY
PE
NE
DL
3. Fathers/Husbands Name
4. M others Name
5.b) Dated
6. Gender Male
7. Date of Birth
1 9
D D M M Y Y Y Y
Female
9. Mobile No.
12. Centre preferred for Post diploma CET Examination 1st Choice Code
2nd Choice 13. Examination Fee Examination Fee Form Fee (Please mark (X) in the appropriate box) Rs. 3500 Rs. 750 Challan / ID No. :
D D
Code
Amount : Name of the Bank Branch: NBE Copy of Pay-in-Slip / Challan of Indian Bank should be enclosed. 14. Are you pursuing any MD/MS/DNB Post graduate degree programme. If yes, Name of the course:____________________________. 15. Correspondence Address Name : 16. Signature of the Candidate (within the box) Yes No
Address:
City : State :
Pin Code :
P.T.O.
18. Details of MBBS and Post Graduate Diploma Examination (attested copies of Certificates to be attached)
Examination Passed
Subject
Medical College
University
State
Result
No. of Attempts
1st MBBS
2nd MBBS
Final MBBS
P.G Diploma
1. 2. 3. 4. 5.
Two extra recent passport size photographs duly attested. Self attested photocopy of Permanent Registration Certificate of Medical Council of India /State Medical Council. Self attested photocopy of MBBS Degree Certificate and P.G Diploma. Proof of PG diploma being recognized by MCI IMR Certificate specifying additional qualification/ Additional qualification registration certificate issued by MCI/ printout of MCI website showing recognition status of PG Diploma. NBE Copy of Pay-in-Slip / Challan of Indian Bank / Axis Bank
DECLARATION & CERTIFICATION
I here by declare and certify that: a) I have read the general instructions and the rules and regulations of NBE in Bulletin of Information and shall abide by them. 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 and are self attested photocopy of original documents. d) I understand that in case any of the facts stated by me is/are found to be false or any of the documents enclosed by me is/are found to be false, I am liable to be disqualified from appearing in the Examination and if permission granted for appearing in the examination shall be liable to be revoked or any other appropriate action deemed fit by NBE can be taken against me. e) I understand that I am eligible as per instructions given in Bullettin of Information, however, NBE reserves the right to determine final f) eligibility;NBE further reserves the right to cancel the candidature if ineligibility found at any stage. Candidates Name in Block Letters
Date:
/2011
Signature of the Head of Institution with Name and office stamp Date: / /2011 ( In case, Candidate is not working, the above column may be attested by a Gazetted officer)
NOTE : USE / POSSESSION OF MOBILE PHONE / ELECTRONIC DEVICE IS NOT PERMITED IN EXAMINATION PREMISES AND PHOTOCOPY OF THE FILLED UP APPLICATION FORM MUST BE RETAINED BY THE CANDIDATE FOR FUTURE USE.
* * * *
INCOMPLETE APPLICATION FORMS WILL NOT BE CONSIDERED. READ PROSPECTUS CAREFULLY BEFORE FILLING UP THE FORM. PLEASE SUBMIT THIS FORM IN ENVELOPE PROVIDED. USE BLUE/BLACK BALL PEN ONLY
PE
NE
DL
3. Fathers/Husbands Name
4. M others Name
5.b) Dated
6. Gender Male
7. Date of Birth
1 9
D D M M Y Y Y Y
9. Mobile No.
12. Centre preferred for Post diploma CET Examination 1st Choice
EC SP
Challan / ID No. : Amount : Name of the Bank Branch:
EN IM
Code Code Date as on Bank Stamp
D D M M Y Y Y Y
Female
2nd Choice 13. Examination Fee Examination Fee Form Fee (Please mark (X) in the appropriate box) Rs. 3500 Rs. 750 NBE Demand draft shall not be accepted.
NBE Copy of Pay-in-Slip / Challan of Indian Bank should be enclosed. 14. Are you pursuing any MD/MS/DNB Post graduate degree programme. If yes, Name of the course:____________________________. 15. Correspondence Address Name : 16. Signature of the Candidate (within the box) Yes No
Address:
City : State :
Pin Code :
P.T.O.
18. Details of MBBS and Post Graduate Diploma Examination (attested copies of Certificates to be attached)
Examination Passed
Subject
Medical College
University
State
Result
No. of Attempts
1st MBBS
2nd MBBS
Final MBBS
P.G Diploma
1. 2. 3. 4. 5.
Two extra recent passport size photographs duly attested. Self attested photocopy of Permanent Registration Certificate of Medical Council of India /State Medical Council. Self attested photocopy of MBBS Degree Certificate and P.G Diploma. Proof of PG diploma being recognized by MCI IMR Certificate specifying additional qualification/ Additional qualification registration certificate issued by MCI/ printout of MCI website showing recognition status of PG Diploma. NBE Copy of Pay-in-Slip / Challan of Indian Bank / Axis Bank
DECLARATION & CERTIFICATION
I here by declare and certify that: a) I have read the general instructions and the rules and regulations of NBE in Bulletin of Information and shall abide by them. 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 and are self attested photocopy of original documents. d) I understand that in case any of the facts stated by me is/are found to be false or any of the documents enclosed by me is/are found to be false, I am liable to be disqualified from appearing in the Examination and if permission granted for appearing in the examination shall be liable to be revoked or any other appropriate action deemed fit by NBE can be taken against me. e) I understand that I am eligible as per instructions given in Bullettin of Information, however, NBE reserves the right to determine final eligibility;NBE further reserves the right to cancel the candidature if ineligibility found at any stage. f) Candidates Name in Block Letters
Date:
/2011
Signature of the Head of Institution with Name and office stamp Date: / /2011 ( In case, Candidate is not working, the above column may be attested by a Gazetted officer)
NOTE : USE / POSSESSION OF MOBILE PHONE / ELECTRONIC DEVICE IS NOT PERMITED IN EXAMINATION PREMISES AND PHOTOCOPY OF THE FILLED UP APPLICATION FORM MUST BE RETAINED BY THE CANDIDATE FOR FUTURE USE.