Online Application Form

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Name

Phone

If studied Abroad, have you passed FMG screening exam

Location

MCI / State Medical council registration number: (Please attached Registration Copy)

Click or drag a file to this area to upload.

Educational Details:

Detail your experience placing the most recent first. Include final or current position.

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Year Of Passing

University

Qualification

Have you applied for this FCCM course earlier / discontinued / rejected

Detail your experience placing the most recent first. Include final or current position.

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From

Position

Presentations and Publications

Employer

Current employer (Name of the Institution)

terms

I have read the instruction manual for the students and I understand all the rules and regulations of this course and assure that I will comply with all of them. I also understand that this FCCM course is under the purview of Society for Emergency Medicine, India (SEMI) only and not under medical council in India or abroad.

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Name

(Attached the CV here)

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Date