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					   KRISHNA INSTITUTE OF MEDICAL SCIENCES




                              APPLICATION FORM

          NATIONAL BOARD OF EXAMINATIONS




# 1-8-31/1, Minister Road, Begum Pet, Hyderabad-500 003, A.P., INDIA. Tel: +91-(0)40-2781 4910-19,
Fax: 91-(0)40-2784 0980, <e-mail: kims@sify.com,e-mail:info@ kims- hospital.com> ,Web site: www.kims.co.in .
                 APPLICATION
 For admission to Diplomate of National Board (DNB) Course


       SUBJECT                                YEAR

NAME (BLOCK LETTERS):

AGE:                                      DATE OF BIRTH      :

SEX:                                      MARITAL STATUS:

MOTHER TONGUE:                            NATIVE DISTRICT & STATE:

NATIONALITY:                              RELIGION:

PRESENT ADDRESS:




TELEPHONE NO:                             e-mail:


PERMANENT ADDRESS:




NAME & ADDRESS OF
PARENT / GUARDIAN:




TELEPHONE NO:                             e-mail:                    FAX:
EDUCATION QUALIFICATIONS:

  Examination passed   Name of the Institution   University Year of passing




WORK EXPERIENCE:




Documents to be submitted along with the application and a
Demand Draft of Rs. 1000/- drawn in favour of Krishna Institute of
Medical Sciences, Secunderabad.

  Certified copies of following:

  1. SSC or an equivalent examination showing date of birth and
     other particulars of the candidate.
  2. MBBS Certificate.
  3. State Medical Council Registration Certificate.
  4. Central Examination Test Certificate.
  5. Two Testimonials from the Professors / Consultants under whom
     you have worked.
  6. 6 latest passport size photographs (one to be pasted on
     application).
SPORTS & EXTRA CURRICULAR ACTIVITIES :




Have you been prosecuted by the law at any time of your professional
service or Education:




                                DECLARATION


I __________________________________ here by solemnly and sincerely affirm that
the statement made and information given by me in the application form and also in
all the enclosures submitted by me are true and correct . I have not kept any
information secret. Should it, however be found that any information furnished
there in is fraudulent, incorrect or untrue, my selection or admission may be
cancelled and I am liable to criminal prosecution.

I shall abide by the decision of the selection committee which shall be final and
binding on me.


Signature of the Applicant


Note:

1. Incomplete applications and applications without necessary certificates will not
   be considered.

2. Applications submitted with incorrect information or false certificate on
   scrutiny will be rejected.

				
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