Sri Kanchi Kamakoti Medical Trust, Sankara Eye Centre, Coimbatore - 641035

SANKARA EYE HOSPITAL, PAMMAL, CHENNAI

Application for admission to DIPLOMATE OF NATIONAL BOARD for the year ______

1. Name of the candidate : ……………………………………………………………

(With expansion of initials) : …………………………………………………………….

: ……………………………………………………………

2. Nationality : ……………………………………………………………

3. Sex : ……………………………………………………………

4. Marital Status : ……………………………………………………………

5. Date of Birth : ……………………………………………………………

6. Parent’s/ Guardian’s/ Husband’s Name & Occupation : ……………………………………………………………

7. Address

Present : ……………………………………………………………

: ………………………………Telephone No. …………

:…………………………………………………………….

Permanent : …………………………………………………………….

:………………………………Telephone No. …...... …

: …………………………………………………………….

1 8. Data of Academic Career :

Name of the Regd.No. Year of Passing Distinction Institution

9. Merit of Scholarship obtained if any :

10.Particulars of M. B. B. S. Course a) Name of the Medical College (University to which it is affiliated) b) Marks obtained in Clinical & Non-Clinical subjects every year

Subjects Marks Year

c) Marks obtained in Ophthalmology:

d) Where there is any failures in any examination during the medical courses (Specially subject (s) and numbers of attempt in each) :

e) Grade obtained in final MBBS :

2 f) Date of completion of internship : g) Registration No.and Name of Medical Council Registered :

h) Have you obtained any certificate of of merit or medal or any other award for meritorious performance during medical course :

i) Nature of work done after completing MBBS Course :

11.Have you passed any other courses in Medicine other than MBBS (give details) :

12.Are you a Employee (State, central OR private) give details :

13.Any special training in Ophthalmology:

14.What are your Extra-Curricular Activities (Distinction achieved)

a) Sports :

b) NCC :

c) Social Work :

d) Any other (Specify):

15.Have you prepared and presented scientific papers On Medical subjects at a conference, or Meet, or was such work included for publication?

……………………………………………………………………………………………….. ………………………………………………………………………………………………..

16.Name two references, their address and Tel No. to whom enquires can be directed regarding your professional capabilities?

3 17.Have you passed DNB Primary?

……………………………………………………………………………………………….. ………………………………………………………………………………………………..

Check List of Photostat copies of certificates to be enclosed (to be produced at interview by candidates applying online). Number all the enclosures in the following order marking a tick () in the dotted line

Encl No: 1. MBBS Degree……………… 2. Medical Council Registration Certificate……………… 3. Internship Completion Certificate……………… 4. Conduct Certificate from college last studied……………… 7. Marksheet of MBBS Examination in Clinical and Non Clinical Subjects…………… 8. Certificates, prizes and Medals Won……………… 9. Any Research Paper accepted……………… 10.Any Publication accepted……………… 11.Service Certificate (if applicable) ……………… 12.Primary DNB Pass Certificate………………

Total Number of Enclosures……………………..

I hereby declare that the particulars furnished by me in the columns above are true and correct to the best of my knowledge.

Date: ………………… Signature

N.B. 1. You can either submit this form by email at [email protected] or mail us at the address below.

Mailing Address:

Sankara Eye Hospital No.1, Third Cross Street, Sri Sankara Nagar, Pammal, Chennai – 600075 Tamil Nadu  044-22484799, 22485299