Diwan Chand Satya Pal Aggarwal Imaging Research Center
10-B, Kasturba Gandhi Marg, New Delhi - 110001

APPLICATION FOR ADMISSION TO
POST GRADUATION DIPLOMA COURSE
NATIONAL BOARD

SPECIALITY: RADIO DIAGNOSIS

Personal Details
Name (in block letters)		(The name should correspond with the name recorded on degree certificate)
Father's Name & Occupation
Date of Birth
Nationality
Marital Status	Married Unmarried
State to which you belong
Present Occupation
Permanent Address
Local Address
Telephone No. if any		Residence
		Office
NB: Any Change in address should be communicated to the center

Sl.No.	Designation (mention the subject)	Period of Appointment From To	Dept.	Institution
Professional details
If you are working/worked as Houseman/Junior Research Fellow/ Senior resident or holding any other paid job, please furnish the following information:
1		-
2		-
3		-
4		-
5		-

DETAILS OF EXAMINATION PASSED

Date of admission to M.B.B.S. Course
Date of completing the House Job/1^st year Junor Residency(Where applicable)
Registration with State Medical Council/M.R.I. No	Date
Medal and/or prize obtained if any

DETAILS OF MARKS OBTAINED AT DIFFERENT EXAMINATIONS FOR THE M.B.B.S.

1^st MBBS Examination Passed in the year

2^nd MBBS Examination Passed in the year

Final MBBS Examination Passed in the year

Details of Compulsory Internship done in the departments of recognised institution:

Details of House job/Junior residency in the departments of recognised institution/hospital

Details of work done other than house job/junior Residency (where applicable)

Designation	Period of service From to	Department/institution/Hospital etc.
	-
	-
	-

Declaration by the applicant

I have read the bulletin of information and have noted its contents and directions for admission to post graduate course (Diplomate N.B)
In the event of any information given by me is found wrong, my admission to the course is liable to be cancelled.
In case I fail to join the course applied for within the prescribed date, my selection to the course will be treated as cancelled.

Attested copies of the following certificates should be enclosed with application in order as given bellow:

One color passport size photograph
MBBS Degree
MBBS detailed marks certificate(1st, 2nd & Final MBBS)
Internship certificate from the head of Institution.
Certificate(s) of House Job in Specialities/Departments from the head of the institution with exact dates in each speciality.
Matriculation/Higher Secondary Certificate for date of birth.
Employer's certificate if you are in service.
Registration with state Medical Council/M.C.I