Name in full* must provide value
[As given in the Qualifying Examination (MBBS/MD)]
Upload passport size photo* must provide value
( MB)
Upload PNG, JPEG, JPG files (Not more than 100 kb)
Father's name* must provide value
Mother's name* must provide value
Date of birth* must provide value
Today D-M-Y Gender* must provide value
Male Female Others Marital status* must provide value
Married Unmarried Divorced/Separated
Nationality* must provide value
Indian Others State / Union Territory to which you belong* must provide value
Email ID * must provide value
Mobile phone number* must provide value
Office phone number
Alternate phone number* must provide value
Door/Flat/Block Number* must provide value
Street/Locality/Area name* must provide value
Town/City* must provide value
District* must provide value
State* must provide value
Pincode* must provide value
Door/Flat/Block Number* must provide value
Street/Locality/Area name* must provide value
Town/City* must provide value
District* must provide value
State* must provide value
Pincode* must provide value
Examination Passed* must provide value
Graduation
Post Graduation
Doctorate/ Ph.D
Additional Qualification
Name of the UG* must provide value
Name of the Institution / University* must provide value
Duration of the Course* must provide value
Month and Year of Admission* must provide value
Month and Year of Passing* must provide value
Percentage of marks obtained* must provide value
No. of failures, if any* must provide value
Name of the PG* must provide value
Name of the Institution / University* must provide value
Duration of the Course* must provide value
Month and Year of Admission* must provide value
Month and Year of Passing* must provide value
Percentage of marks obtained* must provide value
No. of failures, if any* must provide value
Doctorate/ Ph.D* must provide value
Name of the Institution / University* must provide value
Duration of the Course* must provide value
Month and Year of Admission* must provide value
Month and Year of Passing* must provide value
Percentage of marks obtained* must provide value
No. of failures, if any* must provide value
Additional Qualification* must provide value
Name of the Institution / University* must provide value
Duration of the Course* must provide value
Month and Year of Admission* must provide value
Month and Year of Passing* must provide value
Percentage of marks obtained* must provide value
No. of failures, if any* must provide value
1. Copy of the document for age proof:- Secondary School Leaving Certificate (10th Std), Higher Secondary Certificate (12th Std) / Matriculation pass certificate, Birth certificate.
2. Copy of the certificates of academic qualifications:- Graduation, Post Graduate certificate, Doctorate/PhD certificate, attempt Certificates for examinations passed.
3. Additional qualifications (if any)
* must provide value
( MB)
Merge all the documents into single PDF and PDF size should not exceed 10MB.
Are you employed?* must provide value
Yes No Designation* must provide value
Nature of duties* must provide value
Type of Organization / Department* must provide value
Government Government Undertaking Government Project Private
If Government employee, whether the service is permanent* must provide value
Yes No If permanent Government employee, whether the service has been regularized (i.e. Probation completed)* must provide value
Yes No Name* must provide value
Door/Flat/Block Number* must provide value
Street/Locality/Area name* must provide value
Town/City* must provide value
District* must provide value
State* must provide value
Pincode* must provide value
Phone and Fax number* must provide value
Email
Name* must provide value
Door/Flat/Block Number* must provide value
Street/Locality/Area name* must provide value
Town/City* must provide value
District* must provide value
State* must provide value
Pincode* must provide value
Phone and Fax number* must provide value
Email
Name* must provide value
Door/Flat/Block Number* must provide value
Street/Locality/Area name* must provide value
Town/City* must provide value
District* must provide value
State* must provide value
Pincode* must provide value
Phone and Fax number* must provide value
Email
Name* must provide value
Door/Flat/Block Number* must provide value
Street/Locality/Area name* must provide value
Town/City* must provide value
District* must provide value
State* must provide value
Pincode* must provide value
Phone and Fax number* must provide value
Email
Number of services upto till date* must provide value
Name and address of the Institution* must provide value
Type of Organization / Department* must provide value
Government Government Undertaking Government Project Private
Position held* must provide value
Nature of duties* must provide value
Period From* must provide value
Today D-M-Y Period To* must provide value
Today D-M-Y Name and address of the Institution* must provide value
Type of Organization / Department* must provide value
Government Government Undertaking Government Project Private
Position held* must provide value
Nature of duties* must provide value
Period From* must provide value
Today D-M-Y Period To* must provide value
Today D-M-Y Name and address of the Institution* must provide value
Type of Organization / Department* must provide value
Government Government Undertaking Government Project Private
Position held* must provide value
Nature of duties* must provide value
Period From* must provide value
Today D-M-Y Period To* must provide value
Today D-M-Y Name and address of the Institution* must provide value
Type of Organization / Department* must provide value
Government Government Undertaking Government Project Private
Position held* must provide value
Nature of duties* must provide value
Period From* must provide value
Today D-M-Y Period To* must provide value
Today D-M-Y Name and address of the Institution* must provide value
Type of Organization / Department* must provide value
Government Government Undertaking Government Project Private
Position held* must provide value
Nature of duties* must provide value
Period From* must provide value
Today D-M-Y Period To* must provide value
Today D-M-Y Name and address of the Institution* must provide value
Type of Organization / Department* must provide value
Government Government Undertaking Government Project Private
Position held* must provide value
Nature of duties* must provide value
Period From* must provide value
Today D-M-Y Period To* must provide value
Today D-M-Y Name and address of the Institution* must provide value
Type of Organization / Department* must provide value
Government Government Undertaking Government Project Private
Position held* must provide value
Nature of duties* must provide value
Period From* must provide value
Today D-M-Y Period To* must provide value
Today D-M-Y Name and address of the Institution* must provide value
Type of Organization / Department* must provide value
Government Government Undertaking Government Project Private
Position held* must provide value
Nature of duties* must provide value
Period From* must provide value
Today D-M-Y Period To* must provide value
Today D-M-Y Name and address of the Institution* must provide value
Type of Organization / Department* must provide value
Government Government Undertaking Government Project Private
Position held* must provide value
Nature of duties* must provide value
Period From* must provide value
Today D-M-Y Period To* must provide value
Today D-M-Y Name and address of the Institution* must provide value
Type of Organization / Department* must provide value
Government Government Undertaking Government Project Private
Position held* must provide value
Nature of duties* must provide value
Period From* must provide value
Today D-M-Y Period To* must provide value
Today D-M-Y Upload copy of the relevant documents, viz., Appointment order/s, Promotion order/s, Nature of Duties or Work certificates, Proof of experience till date etc.* must provide value
( MB)
Merge all the documents into single PDF and PDF size should not exceed 10MB.
Have you served in the Armed Forces?* must provide value
Yes No Position held* must provide value
Nature of duties* must provide value
Number of years of service* must provide value
No Objection Certificate from the employer [can be submitted with this application or any time before joining the course] [No Objection Certificate Format ] ( MB)
Registration number* must provide value
Registration date* must provide value
Today D-M-Y State/UT* must provide value
Upload copy of Medical Registration certificate* must provide value
( MB)
Details of scientific publications including Thesis ( MB)
Upload the list if any
Details of membership with professional bodies* must provide value
Are you a member of any Association, Union or Federation in your parent department or from any other organization* must provide value
Yes No Name of the association* must provide value
Details of membership* must provide value
Ordinary member Committee member Management member
Any other information relevant to the public health work, which you may like to give in support of your application* must provide value
Reference/Transaction No.* must provide value
Date of transaction* must provide value
Today D-M-Y Who paid the fees? (Mention the name)* must provide value
DECLARATION BY THE APPLICANT
1. I agree to undergo the programme on a fulltime basis and shall not engage myself in private practice during the period of the programme.
2. I agree that during my stay at the Institute, I shall not draw any Fellowship from any other source if I am paid Scholarship / Fellowship by the SCTIMST / ICMR-NIE.
3. I agree that during the course period, I will not participate in any strike, demonstration, etc., pertaining to my affiliation to any of the Association, Union or Federation in my parent department or of any other Organization.
4. I hereby declare that the information given by me in this application is true and correct and no information has been suppressed to the best of my knowledge and belief. In case any information given by me is proved to be false or incorrect at any stage, I shall be responsible for the consequences, which may include among other things, cancellation of my admission, be at any stage.
5. I further declare that I shall maintain good conduct, pay the requisite fee and other charges by the due dates, attend my classes and duties regularly, and abide by the rules and regulations of the Institute/s without fail.
* must provide value
Accept
Submitted by:* must provide value
[Write name]