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    All India Institute of Medical Sciences

    Uploaded by

    MD RAHUL ALAM
    This document is a registration form for the Institute of National Importance Combined Entrance Test (INI-CET) for admission to various postgraduate medical courses. It contains details of the candidate such as name, date of birth, gender, category, nationality, identification marks, contact details, qualification details, internship details, medical registration details, valid photo identity, payment details, and examination city preferences. The candidate has declared that the information provided is correct and acknowledges potential consequences of providing false information.

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    © All Rights Reserved
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    All India Institute of Medical Sciences

    Uploaded by

    MD RAHUL ALAM
    64 views2 pages
    This document is a registration form for the Institute of National Importance Combined Entrance Test (INI-CET) for admission to various postgraduate medical courses. It contains details of the candidate such as name, date of birth, gender, category, nationality, identification marks, contact details, qualification details, internship details, medical registration details, valid photo identity, payment details, and examination city preferences. The candidate has declared that the information provided is correct and acknowledges potential consequences of providing false information.

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    This document is a registration form for the Institute of National Importance Combined Entrance Test (INI-CET) for admission to various postgraduate medical courses. It contains details of the candidate such as name, date of birth, gender, category, nationality, identification marks, contact details, qualification details, internship details, medical registration details, valid photo identity, payment details, and examination city preferences. The candidate has declared that the information provided is correct and acknowledges potential consequences of providing false information.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    64 views2 pages

    All India Institute of Medical Sciences

    Uploaded by

    MD RAHUL ALAM
    This document is a registration form for the Institute of National Importance Combined Entrance Test (INI-CET) for admission to various postgraduate medical courses. It contains details of the candidate such as name, date of birth, gender, category, nationality, identification marks, contact details, qualification details, internship details, medical registration details, valid photo identity, payment details, and examination city preferences. The candidate has declared that the information provided is correct and acknowledges potential consequences of providing false information.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Firefox https://finalmdmsmch.aiimsexams.org/RegistrationSlip?id=K+fjOQ+g...

    All India Institute of Medical Sciences


    Ansari Nagar, New Delhi - 110608

    Registration Form - Institute of National Importance Combined Entrance Test (INI-CET) for admission to PG courses [MD/MS/M.Ch.(6years)/DM(6years)/MDS] JULY
    2021 Session

    Candidate Profile Registration ID: P6151282578 Payment ID: 30007241 Examination Unique Code: 8111752

    Candidate Name: MD RAHUL ALAM Applied Course: MD/MS/MCH(6YRS)/DM(6YRS)

    Date of Birth: 17 Dec 1994 Category: General

    Gender: Male Marital Status: Unmarried

    Father's Name: MD GOLAB ALI Mother's Name: SAIJARUN NESA BEGAM

    PWBD Status: No PWBD Category: NA

    Nationality: INDIAN Applied Under: General

    Identification Mark(1): NO Identification Mark(2): NO

    Are you currently pursuing PG Course in any Subject: NO Do you belong to Karnataka Domicile Category:
    NO

    Do you belong to North East Domicile Category: YES Do you want to apply for Bhutani National
    Candidate : NA

    Service in Armed Forces (as per note 3 of Appendix-E)?: NA Service in Central/State Govt. of 3 years or more
    (as per note 3 of Appendix-E)? : NA

    Applied for PGIMER,Chandigarh under Sponsored Category (Indian National)?: NA Applied for JIPMER,Puducherry under Sponsored
    Category (Indian National)? : NA

    Applied for AIIMS(Delhi/Rishikesh) under Sponsored Category (Indian National)?: Do you want to apply for NIMHANS,Bengaluru
    NA under Sponsored Category(Indian National) : NA

    Contact Details

    Address for Permanent: Correspondence Address:


    S/O- MD GOLAB ALI, PEC BRICK FIELD , SOUTH RAMNAGAR, Agartala , S/O- MD GOLAB ALI, PEC BRICK FIELD , SOUTH RAMNAGAR, Agartala , West
    West Tripura, TRIPURA, India, 799001 Tripura, TRIPURA, India, 799001

    Mobile No: 1. 8794879721 , 2. Alternate-MobileNo 0 E-Mail ID: rahulalam66.ra23@gmail.com

    Qualification Details

    Qualifying Examination Degree From State Name Admission Date Passing Date

    MBBS Indian University Tripura 12/07/2013 14/03/2018

    University Name Institute/College Name


    TRIPURA UNIVERSITY Tripura Medical College & Dr. BRAM Teaching Hospt., Agartala

    Academic Details

    Qualifying Exam Max Marks Marks Obtained Percentage(%)


    MBBS 2450.00 1496.00 61.06

    Internship Details

    Internship Status Internship Start Date Completion/Expected Completion Date No. of Days
    Completed 19/03/2018 02/04/2019 380

    Medical Registration Details

    Registration Type Registration Date Registration Number Registering Authority


    Permanent 05/04/2019 002313 State Council -- (Tripura )

    Valid Photo Identity (To be presented in original at the Examination Center along with Admit Card)

    ID Proof: Adhar Card ID No: 286597403231 Place of Issue: India Issue Date: NA Valid Till: NA

    Do you have experience : No

    Payment Details

    1 of 2 26-Mar-21, 7:36 AM
    Firefox https://finalmdmsmch.aiimsexams.org/RegistrationSlip?id=K+fjOQ+g...

    Mode: Online Date: 26/03/2021 Transaction ID: 7128257874 Amount: 2000

    Examination City Opted:

    State: Exam City(Preference 1): State : Exam City(Preference 2): State : Exam City(Preference 3): Exam City(Preference 4):

    Madhya Pradesh Bhopal Madhya Pradesh Indore Madhya Pradesh Gwalior Any Other City

    UNDERTAKING/DECLARATION: I hereby declare that the information furnished by me in the Registration/Application Form is correct and nothing has been
    concealed. In case any information furnished by me is found to be false/incorrect/untrue than i shall be liable to civil/criminal prosecution and my claim to
    admission/appointment/registration/ service in the Institute may be cancelled/terminated.

    Signature of Candidate
    Thumb of Candidate

    2 of 2 26-Mar-21, 7:36 AM

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