NATIONAL BOARD OF EXAMINATIONS

(Ministry of Health & Family Welfare, Govt of India)

NAMS BUILDING, ANSARI NAGAR, MAHATMA GANDHI MARG, NEW DELHI-110029
SCANNABLE APPLICATION FORM FOR SCREENING TEST (FMGE) SEPTEMBER 2007
To be filled by Indian nationals with foreign primary medical qualification for submission to the National Board of Examinations,
Ansari Nagar, New Delhi-110029 on their return to India for appearing in the Screening Test for the purpose of their registration.

(To be filled by National Board of Examinations Office) Application Form No.

ID Number Roll Number

DL
1. Name (CAPITAL LETTERS) (Leave a blank space between first, middle & last names) TO BE FILLED IN CAPITAL LETTERS ONLY

2. Father’s/Husband’s Name

3. Mother’s Name

4. Correspondence Address 5. Sex 6. Date of Birth

Male Female 1 9
Name : ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

D D M M Y Y Y Y

Address: ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
E PE NE

○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

Y
SE ONL
CE U
○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ City : ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

I
OFF
State : ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ FOR
Pin Code :

7. STD Code Telephone No./Mobile No. 8. E-mail (Write in Bold & Clear manner) 9. Photograph
1. Paste here (do not pin or staple)
a recent passport size colour
10. Nationality photograph as per
i) By Birth/By Domicile “INSTRUCTIONS FOR
PHOTOGRAPHS” on the inner
ii) Passport No. iii) Date of Issue side of back cover of the
Prospectus.
2. The photograph should NOT
D D M M Y Y Y Y exceed this box.
iv) Date upto which valid v) Place of Issue 3. The photograph to be affixed here
should NOT be attested.
4. If the photograph is not clear,
D D M M Y Y Y Y the application will be rejected.
11. Details of previous/lost passport, if any: i) Reason for change of passport
ii) Previous Passport No. 12. Signature of the Candidate
iv) Date & Place of Issue (within the box)
iii) FIR No. in respect of lost passport
iv) Date of Expiry
13. Percentage of marks of Qualifying Examination passed:
English Physics Chemistry Biology Grand Total

14. Medical Course : Joined on 15. Have you been granted Provisional Registration by MCI
Yes No
or any State Medical Council:
If yes, Please give details of: Registration No. Date
D D M M Y Y Y Y
Completed on
D D M M Y Y Y Y
Name of Council

D D M M Y Y Y Y
16. Examination Fee (Please mark (X) in the appropriate box) CANDIDATE TO ENSURE THAT THE FEES IS PAID BY SINGLE DRAFT ONLY
Bank Draft No. Dated Amount
Examination Fee Rs. 3000
2 0 0 7
* Form Fee Rs. 500
Name of the Bank D D M M Y Y Y Y
(*For downloaded form only) P.T.O.
17. Details of the qualifying Examination passed
Name of the Examination passed
(10+2) OR equivalent):

Subjects Maximum Marks Marks Obtained %age

Board Name & Address
i) English

ii) Physics

iii) Chemistry Month & Year of Passing

iv) Biology
M M Y Y Y Y

v)

GRAND TOTAL

Name of the Institution with Address

18. If done B.Sc., Please give details of examination passed: Subject/Marks/Roll No. & Year of passing / name of the university etc.

19. Details of Primary Medical Qualification

Registration No. Address of the Valid Valid
Year Name of Medical Institution / University
(with city & country) Registering Authority from upto
Preparatory
Course (if any)
1st Year

2nd Year

3rd Year

4th Year

5th Year

6th Year

20. Whether the Medical Institute (s) indicated in S. No. 18 above is/are recognised in the country in
Yes No
which they are situated for award of the primary medical qualification.
21. Internship done in the foreign country

a) Duration b) Rotatory/Otherwise
c) 3 months rural training compulsory d) Periods when internship done from To

Yes No
D D M M Y Y Y Y D D M M Y Y Y Y
e) Place (s) where done

f) Whether the institution where Internship was done, is recognised by the foreign medical Council/
Medical Council of India Yes No

22. Were you ever deported / rusticated 23. Whether obtained Eligibility
during medical course Yes No Certificate from MCI Yes No

DECLARATION

I here by declare & certify that:

a) I am an Indian Citizen,
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 are original / attested photocopy of original documents.
d) I understand that in case any of the fact stated by me are found to be false or any of the documents enclosed by me are found to be fake, I am liable
to be disqualified from appearing in the Screening Test or registration, if granted, shall be liable to be revoked.

Place:

Date: _______________ Signature of the Candidate

 NATIONAL BOARD OF EXAMINATIONS
(Ministry of Health & Family Welfare, Govt of India)
NAMS BUILDING, ANSARI NAGAR, MAHATMA GANDHI MARG, NEW DELHI-110029
NON-SCANNABLE APPLICATION FORM FOR SCREENING TEST (FMGE) SEPTEMBER 2007
To be filled by Indian nationals with foreign primary medical qualification for submission to the National Board of Examinations,
Ansari Nagar, New Delhi-110029 on their return to India for appearing in the Screening Test for the purpose of their registration.

(To be filled by National Board of Examinations Office) Application Form No.

ID Number Roll Number

DL
1. Name (CAPITAL LETTERS) (Leave a blank space between first, middle & last names) TO BE FILLED IN CAPITAL LETTERS ONLY

2. Father’s/Husband’s Name

3. Mother’s Name

4. Correspondence Address 5. Sex 6. Date of Birth

Male Female 1 9
Name : ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

D D M M Y Y Y Y

Address: ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
E PE NE

○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

Y
SE ONL
CE U
○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ City : ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

I
OFF
State : ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ FOR
Pin Code :

7. STD Code Telephone No./Mobile No. 8. E-mail (Write in Bold & Clear manner) 9. Photograph
1. Paste here (do not pin or staple)
a recent passport size colour
10. Nationality photograph as per
i) By Birth/By Domicile “INSTRUCTIONS FOR
PHOTOGRAPHS” on the inner
ii) Passport No. iii) Date of Issue side of back cover of the
Prospectus.
2. The photograph should NOT
D D M M Y Y Y Y exceed this box.
iv) Date upto which valid v) Place of Issue 3. The photograph to be affixed here
should be attested.
4. If the photograph is not clear,
D D M M Y Y Y Y the application will be rejected.
11. Details of previous/lost passport, if any: i) Reason for change of passport
ii) Previous Passport No. 12. Signature of the Candidate
iv) Date & Place of Issue (within the box)
iii) FIR No. in respect of lost passport
iv) Date of Expiry
13. Percentage of marks of Qualifying Examination passed:
English Physics Chemistry Biology Grand Total

14. Medical Course : Joined on 15. Have you been granted Provisional Registration by
Yes No
MCI
or any Please
If yes, State Medical Council:
give details of: Registration No. Date
D D M M Y Y Y Y
Completed on
D D M M Y Y Y Y
Name of Council

D D M M Y Y Y Y
16. Examination Fee (Please mark (X) in the appropriate box) CANDIDATE TO ENSURE THAT THE FEES IS PAID BY SINGLE DRAFT ONLY
Bank Draft No. Dated Amount
Examination Fee Rs. 3000
2 0 0 7
* Form Fee Rs. 500
Name of the Bank D D M M Y Y Y Y
(*For downloaded form only) P.T.O.
17. Details of the qualifying Examination passed
Name of the Examination passed
(10+2) OR equivalent):

Subjects Maximum Marks Marks Obtained %age

Board Name & Address
i) English

ii) Physics

iii) Chemistry Month & Year of Passing

iv) Biology
M M Y Y Y Y

v)

GRAND TOTAL

Name of the Institution with Address

18. If done B.Sc., Please give details of examination passed: Subject/Marks/Roll No. & Year of passing / name of the university etc.

19. Details of Primary Medical Qualification

Registration No. Address of the Valid Valid
Year Name of Medical Institution / University
(with city & country) Registering Authority from upto
Preparatory
Course (if any)
1st Year

2nd Year

3rd Year

4th Year

5th Year

6th Year

20. Whether the Medical Institute (s) indicated in S. No. 18 above is/are recognised in the country in
Yes No
which they are situated for award of the primary medical qualification.
21. Internship done in the foreign country

a) Duration b) Rotatory/Otherwise
c) 3 months rural training compulsory d) Periods when internship done from To

Yes No
D D M M Y Y Y Y D D M M Y Y Y Y
e) Place (s) where done

f) Whether the institution where Internship was done, is recognised by the foreign medical Council/
Medical Council of India Yes No

22. Were you ever deported / rusticated 23. Whether obtained Eligibility
during medical course Yes No Certificate from MCI Yes No

DECLARATION

I here by declare & certify that:

a) I am an Indian Citizen,
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 are original / attested photocopy of original documents.
d) I understand that in case any of the fact stated by me are found to be false or any of the documents enclosed by me are found to be fake, I am liable
to be disqualified from appearing in the Screening Test or registration, if granted, shall be liable to be revoked.

Place:

Date: _______________ Signature of the Candidate

 NATIONAL BOARD OF EXAMINATIONS
(Ministry of Health & Family Welfare, Govt of India)
NAMS BUILDING, ANSARI NAGAR, MAHATMA GANDHI MARG, NEW DELHI-110029
APPLICATION FORM FOR SCREENING TEST (FMGE) SEPTEMBER 2007
To be filled by Indian nationals with foreign primary medical qualification for submission to the National Board of Examinations,
Ansari Nagar, New Delhi-110029 on their return to India for appearing in the Screening Test for the purpose of their registration.

(To be filled by National Board of Examinations Office) Application Form No.

ID Number Roll Number

1. Name (CAPITAL LETTERS) (Leave a blank space between first, middle & last names) TO BE FILLED IN CAPITAL LETTERS ONLY

2. Father’s/Husband’s Name

3. Mother’s Name

4. Correspondence Address

Name : ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
5. Sex

Male Female
D D
N
6. Date of Birth

M M
1 9
Y Y Y Y

Address:

○ ○ ○ ○ ○
○

○
○

○
○

○
○

○
○

○
○

○
○

○
○

○
○

○
○

○
○

○
○

○
○

○
○

○
○

○
○

○
○

○
○

○
○

○
○

○
○

○
○

○
○

○
○

○
○

○
○

○
○

○
E

E PE

SE ONL
Y
NE

CE U
○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ City : ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

I
OFF
State : ○ ○ ○ ○ ○ ○ ○ ○ ○

Pin Code :
○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

M FOR

7. STD Code

10. Nationality
Telephone No./Mobile No.
I
8. E-mail (Write in Bold & Clear manner) 9. Photograph

i) By Birth/By Domicile

ii) Passport No.

C iii) Date of Issue

E
iv) Date upto which valid D D M M Y Y Y Y
v) Place of Issue

D D M M Y Y Y Y
11. Details of previous/lost passport, if any: i) Reason for change of passport
ii) Previous Passport No.

iii) FIR No. in respect of lost passport

P iv) Date & Place of Issue

iv) Date of Expiry

12. Signature of the Candidate
(within the box)

13. Percentage of marks of Qualifying Examination passed:

English Physics Chemistry
S Biology Grand Total

14. Medical Course : Joined on 15. Have you been granted Provisional Registration by
Yes No
MCI
or any Please
If yes, State Medical Council:
give details of: Registration No. Date
D D M M Y Y Y Y
Completed on
D D M M Y Y Y Y
Name of Council

D D M M Y Y Y Y
16. Examination Fee (Please mark (X) in the appropriate box) CANDIDATE TO ENSURE THAT THE FEES IS PAID BY SINGLE DRAFT ONLY
Bank Draft No. Dated Amount
Examination Fee Rs. 3000
2 0 0 7
* Form Fee Rs. 500
Name of the Bank D D M M Y Y Y Y
(*For downloaded form only) P.T.O.
17. Details of the qualifying Examination passed
Name of the Examination passed
(10+2) OR equivalent):

Subjects Maximum Marks Marks Obtained %age

Board Name & Address
i) English

ii) Physics

iii) Chemistry Month & Year of Passing

iv) Biology
M M Y Y Y Y

v)

GRAND TOTAL

Name of the Institution with Address

18. If done B.Sc., Please give details of examination passed: Subject/Marks/Roll No. & Year of passing / name of the university etc.

19. Details of Primary Medical Qualification

Registration No. Address of the Valid Valid
Year Name of Medical Institution / University
(with city & country) Registering Authority from upto
Preparatory
Course (if any)
1st Year

2nd Year

3rd Year

4th Year

5th Year

6th Year

20. Whether the Medical Institute (s) indicated in S. No. 18 above is/are recognised in the country in
Yes No
which they are situated for award of the primary medical qualification.
21. Internship done in the foreign country

a) Duration b) Rotatory/Otherwise
c) 3 months rural training compulsory d) Periods when internship done from To

Yes No
D D M M Y Y Y Y D D M M Y Y Y Y
e) Place (s) where done

f) Whether the institution where Internship was done, is recognised by the foreign medical Council/
Medical Council of India Yes No

22. Were you ever deported / rusticated 23. Whether obtained Eligibility
during medical course Yes No Certificate from MCI Yes No

DECLARATION

I here by declare & certify that:

a) I am an Indian Citizen,
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 are original / attested photocopy of original documents.
d) I understand that in case any of the fact stated by me are found to be false or any of the documents enclosed by me are found to be fake, I am liable
to be disqualified from appearing in the Screening Test or registration, if granted, shall be liable to be revoked.

Place:

Date: _______________ Signature of the Candidate