Mci Eligibility Application Form – Fill Out and Use This PDF

Form-MCI-01

MEDICAL COUNCIL OF INDIA

Pocket - 14, Sector - 8, Phase-I, Dwarka, New Delhi – 110 077

Phone : 011-25367033,25367035, 25367036

Email : mci@bol.net.in, Website : www.mciindia.org

APPLICATION FORM FOR ELIGIBILITY CERTIFICATE

(1)Name in Capital letters (according to 12th Class Certificate or its equivalent) ….……………..……………

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

(2)Father’s Name ……………………………………….……………..………………………………………………

(4)Nationality ……………………………………… Date of Birth ………………………………………………….

(6)Category (General/SC/ST/OBC) …….………..…………..…………………….………………………………

(7)Two visible identification marks : (a) ……..………………..……………………………………………………

(b)……………………………………...……..………………….………………………………….…..……………

(8)Present Address in capital letters (including pin code no & phone no) ………………………………………

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

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

(9)Permanent Address in capital letters (including pin code no. & phone no.) ………..…………….…………

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

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

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Form-MCI-01

(10)Details of educational qualifications from 11th standard onwards:

11th Class details :

•School Name & Address …………………………...……………..…………………………………………..

•Board Name & Address ……………………………………….………………………………………………

•Roll No…….………….………………………………. Result………………………………………………..

•Certificate No. & Date ……………………………………………………………..…………………………

•Date of Joining & Date of Completion.……………………………………………………………………..

Subjects	Maximum Marks		Marks Obtained		% Result
	Theory	Practical	Theory	Practical	Pass/Fail

English

Physics

Chemistry

Biology

PCB Total

12th Class/ Intermediate or 10+2 details :

•School Name & Address …………………………...……………..…………………………………………..

•Board……………………………………….…………………………Roll No…….………….………………

•Date of Joining …………….…..……………. ……………..Date of Passing …..…………………………

•School Code No. ……………………….……………………………………………………………………..

Subjects	Maximum Marks		Marks Obtained		% Result
	Theory	Practical	Theory	Practical	Pass/Fail

English

Physics

Chemistry

Biology

PCB Total

B.Sc. or any other University Examination. (if any) :

•College Name & Address ……………………………….………………………………...………………..…

•University ….…………………………………………………………………………………………………….

……….……………………………….………………………Roll No…….…………...…….……………….…

•Date of Joining ..………………………..…. Date of Passing …..………………………………..…………

Grand Total

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Form-MCI-01

(11)Name of the Foreign Medical College/Institution wherein Admission Is sought by the Candidate……………………………………...…………………………………….………………………………

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

(12)Name of the Foreign Medical University to which the Foreign Medical College/Institution with country name mentioned in Col. No. 11 above, is affiliated ………………………………………………….…………

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

(13)Year of admission in Foreign Medical College/Institution ……………………..…………………..…………..

Name and address of issuing bank…………………………………………………………………

Demand Draft Number and date ……………………………………………………………………

Amount Rs……………………………………………………………………………......................

(b)Verification Fees (as prescribed by concerned board) Details:

(i)Name & Address of issuing bank…………………………………………………………………….

(ii)Demand Draft Number and date …...……………………………………………………………….

(iii)Demand Draft in Favour of …………………………………………………………………………..

(iv)Amount Rs…………………………………………………………………………………….............

(15)Email address of the candidate: …………….……………………………………………………………………

(16)Mobile No of the Candidate………………………………………………………………………………………..

.

(Signature of Candidate)

Place : …………………..

Date : …………………..

NOTE: THE APPLICANT MUST PROVIDE HIS/HER EMAIL ADDRESS AND MOBILE NO. THE CERTIFICATES OF THE CANDIDATES WILL BE MADE AVAILABLE ONLINE ON OUR WEBSITE www.mciindia.org ON OR AFTER 27th FEBRUARY,2013 UNDER “APPLY ONLINE PORTAL”. A LOGIN ID AND PASSWORD WILL BE PROVIDED TO THE APPLICANTS THROUGH SMS AND E-MAIL BY WHICH THEY CAN DOWNLOAD THEIR CERTIFICATES AND CAN TAKE PRINT OUT.

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Form-MCI-01

DECLARATION

I declare that the entries made by me in this Form are true to my knowledge and I understand that I am liable for action under the law for any false information or document produced by me without any notice from MCI, New Delhi.

I also understand that the Medical Council of India shall be free to investigate on its own into the correctness of information furnished by me in this application and/or call for any further information in this regard from me and in the event of any information furnished by me being found to be incorrect or false during such investigation or at any subsequent stage, the Council may refuse to issue the eligibility certificate or if already issued may cancel the same and I shall stand debarred from appearing in the Screening Test prescribed in Sub-Section(4A) of Section 13 of the Indian Medical Council Act, 1956 and any other rule and regulation framed by MCI, New Delhi without any notice.

I understand that after obtaining the foreign recognized primary medical qualification, and subject to the verification as contained above, I have to pass a screening test prescribed under the Indian Medical Council Act, 1956 read with the Eligibility Requirement for taking Admission in an Undergraduate Medical Course in a Foreign Medical Institution Regulations, 2002 and the Screening Test Regulations, 2002 before grant of provisional/permanent registration by the Medical Council of India or any of the State Medical Councils.

(Signature of Candidate)

Name……………….………........

Place : …………………..

Date : …………………..

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Form-MCI-01

CHECK LIST

(for submission of documents)

The candidates are requested to ensure that the documents be enclosed as per the order in the Checklist. All papers/documents should be numbered and arranged according to the checklist. In the following order & tick mark the relevant box:

S.NO.	Particulars/Details	Whether
		Yes or No
1	Check list	Yes	No
2	Bank Draft for Rs.1,000/-	Yes	No
3	Whether candidate’s name, Father’s name, phone no. & purpose has been	Yes	No
	written on the back of DD/Pay order duly singed by the candidate
4	Application form	Yes	No
5	Three attested copies of Passport	Yes	No
6	Three attested copies of Pass Certificate of 10th Class or equivalent examination	Yes	No
7	Three attested copies of Pass Certificate of 11th Class or equivalent examination	Yes	No
8	Three attested copies of Marksheet of 12th Class (10+2) or equivalent	Yes	No
	examination
9	Three attested copies of Pass Certificate of 12th Class (10+2) or equivalent	Yes	No
	examination.(showing all the subjects & the name of the school)
10	Three attested copies of School/College Leaving Certificate for Bihar Board	Yes	No
	Students & for Tamilnadu Board Students
11	Three attested copies of B.Sc. Marksheet - if the candidate obtained less	Yes	No
	than 50% marks for General and 40% marks for Reserve Category
12	Three attested copies of OBC/SC/ST Certificate	Yes	No
	(mention the Caste Certificate number, date and name and address of the Issuing
	authority on the back side of copy of the certificate )
13	Three attested copies of English Translation of OBC/SC/ST Certificate -	Yes	No
	(if the Certificate is in regional language) .
14	One additional colour passport size photograph with front view	Yes	No
15	Three attested copies of Admission/Acceptance letter of Foreign Medical	Yes	No
	University
16	Additional DD for Verification of 10+2 marksheet/Certificate, as per list given	Yes	No
	in the instructions
17	Original Certificates for Serial No 6 to Sr. No 13.	Yes	No

Dated …………………………

(Signature of Candidate)

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Form-MCI-01

(NEW PAGE INSERTED)

MEDICAL COUNCIL OF INDIA

Pocket - 14, Sector - 8, Phase-I, Dwarka, New Delhi - 110 077

Phone : 011-25367033,25367035, 25367036

Email : mci@bol.net.in, Website : www.mciindia.org

THREE NON-ATTESTED

PHOTOGRAPHSPECIMEN SIGNATURE OF THE CANDIDATE

Colour Photograph

(Signature of the Candidate)

Colour Photograph

(Signature of the Candidate)

Colour Photograph

(Signature of the Candidate)

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Form-MCI-01

INSTRUCTIONS

(Read Instructions carefully before filling up the Eligibility

1)Incomplete documents and applications without originals will not be accepted. Application must be complete in all respects. No alteration will be allowed to be made in the application form after it has been submitted to the Council.

2)The applicant who applies through post must enclose the originals properly tagged along with the application form.

3)The Form should be filled up using Capital letters in candidate’s own legible handwriting.

4)Demand draft for Rs.1000/- (Rupees One Thousand only) in favour of “The Secretary,

Medical Council of India”, Payable at New Delhi. On reverse of demand draft please mention applicant’s Name, Father’s Name, purpose for which the draft submitted and Telephone Number. Applicant is required to affix one recent front view colour photograph duly attested by a Gazetted Officer on the application form.

5)All the documents should be submitted in original (along with three legible attested photocopies)

6)Original Matriculation Certificate showing Date of Birth (with three attested photocopies.)

7)Original Marksheet of the 11th class (with three attested photocopies).

8)Original +2 Marksheet & Pass Certificate (with three attested photocopies).

9)Original and three attested copies of School/College Leaving Certificate for Bihar Board Students

10)Original SC/ST/OBC Certificate (with three attested photocopies) (in case of reserved category candidates) and a copy of English Version in case of Caste Certificate is in regional language.

11)Original Proof of Admission in Foreign Medical University (alongwith three attested photocopies)

12)Applicant to retain one copy of application form and draft for future reference.

13)Equivalency Certificate from AIU to the +2 equivalent qualifications, if obtained from abroad.

14)Fee for verification of qualifying examination as prescribed by the State Boards/Universities concerned, as mentioned below in Column No. 16

15)Verification fees to be submitted by way of DD/Pay Order by the candidate who have qualified 10+2 examinations from the following States :

VERIFICATION FEE WILL BE SUBMITTED ONLY IN FORM OF DEMAND DRAFT/PAY ORDER

SNo	State/Board	Amount	In favour of

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Form-MCI-01

MEDICAL COUNCIL OF INDIA

Pocket - 14, Sector - 8, Phase-I, Dwarka, New Delhi - 110 077

Phone : 011-25367033,25367035, 25367036

Email : mci@bol.net.in, Website : www.mciindia.org

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Form-MCI-01

ACKNOWLEDGEMENT

(to be filled by the candidate)

Received Application from Ms/Mr.…………………………………………………………………

D/o / S/o Sh……………...………………………………………......... alongwith Bank Draft

Receipt No…………………………… dated..………………………….. for Rs 1000/- (Rs. One

thousand only) Drawn on Bank………………………………………………………………………

for issuance of Eligibility Certificate u/s 12 and 13(4B) of the I.M.C. Act, 1956 for consideration.

OFFICIAL	Signature of Receiving Official
SEAL	with date

Email of Eligibility Section : eligibility@mciindia.org

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