« General Practitioners  
       
       
       
       
       
  Application Form ...  
   
     
 
 
 
1. Name
 
2. Father Name  
 
3. Date of Birth
 
4. Present Address 
 
 
5. Permanent Address
 
6. Nationality 
 
7. Professional Qualification
 
    Date of Qualification   
Institution
   
MBBS/ MD  
   
Other post Graduate Qualification
 
(if any)  
 
8. B. M. D. C. Registration     
 
9. Experience after Medical Graduation
 
10. Duration of General Practice
 
Duration
 
Period From
 
To
 
11. Publications (if any)
 
 
12. Any Other Contribution (if any)
 
13. Subject of Dissertation in FCGP Course
 
(any one of the following).
 
14. Enclosure
 
(a) Three copies of passport sized recent photograph
(b) Photo copies of Professional qualification certificates
(c) Photo copy of B.M.D.C. registration certificate
(d) Proof of BPMPA Life Membership
(e) Photo copy of the receipt of the course fees
I hereby certify that the above Statement is and correct
     
 
Date
Signature of Candidate
 
   
 
     
     
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