Proforma "A"

1.	Name of the candidate (In full and in block capital letters) with postal address in the Native Country and e-mail address :
2.	Nationality :
3.	Father's Name :
4.	Date & Place of Birth :
5.	Passport No., Date and Place of issue : (Please attach six (6) photocopies)
6.	Address for communication :
7.	Applicant's likely address in India during stay :
8.	Name & Address of the College / University where studying at present :
9.	Year of admission to the College :
10.	Year in which studying :
11.	Examinations passed :
12.	Type of Elective Training the candidate desires to do :
13.	Approximate period of Elective Training in India: (with likely dates of Elective Training)
14.	What do you expect from the Elective Training in India :
15.	A reference letter from the Dean, Medical College / University of the applicant sponsoring the candidate : (Please attach six (6) photocopies of the letter)
16.	Have you taken the minimum time to reach the stage of the course, if not, please explain :
17.	Any other relevant information :
18.	Bank Draft of Rs. 5000/- (non-refundable) - in favour of the Secretary, Medical Council of India, payable at New Delhi. Please note: In some demand drafts there is column for "Branch". This SHOULD be New Delhi (Please mention details of the draft)
19.	A bank draft For Rs.1000/- in favour of the Municipal Corporation of Greater Mumbai - payable in Mumbai (Bombay)- this is the application processing charge. (Plese note: In some demand drafts there is column for "Branch". This SHOULD be Mumbai (Bombay).

 

Signature of the candidate

Date ( dd/mm/yy )

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The forms duly completed should be mailed along with all required documents to :

The Dean,

Seth G.S. Medical College,

Parel, Mumbai 400 012.

India.

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