King Edward Memorial Hospital

1.	Name of the candidate (In full and in block capital letters) with postal address in the Native Country
2.	E mail address:
3.	Nationality :
4.	Father's Name :
5.	Date(DD/MM/YY) & Place of Birth :
6.	Passport No., Date and Place of issue : (Please attach six (6) photocopies)
7.	Address for communication :
8.	Applicant's likely address in India during stay :
9.	*Name & Address of the College / University where you obtained your MBBS degree:**
10.	Name & Address of the College / University where studying at present :
11.	Year of admission to the College :
12.	Specialty in which you are training at present (Internal Medicine, Pediatrics, Orthopedics etc)
13.	Year in which studying :(PGY1, PGY2 etc)
14.	Type/Subject of Elective Training the candidate desires to do :
15.	Approximate period of Elective Training in India: (with likely dates of Elective Training)
16.	What do you expect from the Elective Training in India :
17.	A reference letter from the Dean, Medical College / University of the applicant sponsoring the candidate :(Please attach six (6) photocopies of the letter)
18.	Have you taken the minimum time to reach the stage of the course, if not, please explain :
19.	Any other relevant information :
20.	A Bank Draft** of Rs. 5,000/- (non-refundable) - in favour of the Secretary, Medical Council of India, payable at New Delhi .Please mention details of the draft) ((Please note: In some demand drafts there is column for "Branch". This SHOULD be New Delhi).
21.	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. Please mention the details of the draft (Please note: In some demand drafts there is column for "Branch". This SHOULD be Mumbai (Bombay).

Signature of the candidate

Date ( dd/mm/yy )

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.

1. Six copies of this form.
2. Six copies of Form for Temporary Medical registration.
3. Six passport-sized photographs
4. Six photocopies of your passport
5. Six copies of reference/recommendation letter from the Dean of the medical college/university where you are currently undergoing medical studies
6. A bank draft for Rs.1000*/- (non refundable) in favour of the - Secretary, Medical Council of India payable at New Delhi to enable this office to get permission from the above authorities to allow you to undergo the elective training at these institutions.
7. 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. (Please note: In some demand drafts there is column for "Branch". This SHOULD be Mumbai (Bombay).
8. Six copies of your MBBS** passing certificate.