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(2) Full Name (i.e. Full Name of the Applicant only) (3) Address in Capital letters (e.g. City, State/Province ) (4) Occupation in Capital letters (i.e. Occupation - Doctor, Physi a, Nurse, Nurse Practitioner (i.e. Doctor/Physiotherapist, Physiotherapist -, NP, Nursing) (5) Nationality in Capital letters (i.e. Nationality or Citizenship in India or abroad) (6) Contact Number in Capital letters (7) Telephone No. (8) Email Address in Capital letter (9) Date of birth (i.e. Year, Month, Day Month Day 12th (a) First Name (b) Middle name (i.e. Name of the Second Person) (c) Last Name (d) Date of Birth (i.e. Year, Month, Day Month Day 12th (f) Application Form for Eligibility Certificate (for getting Admission in Graduate Course of a Foreign Medical Institi tion ) : Application form for Eligibility Certificate for getting Admission in a Foreign Medical Institution under 12 and 13( 1B (For getting admission to Graduate Medical Course in, a. University or other Medical Establishment, u/s 12 and 13( 4B) of Indian Medical Council Act, 1956) : Affix completed Form - 1 (1) Name of Eligibility Certificate in English (2) Name of Eligibility Certificate in Hindi (a) First Name for Application (b) Middle Name (c) Last Name (d) Date of Birth - in the form. The form of Eligibility Certificate is available under Forms - 1 & 2. (3) Attributed to the following School : (a) School in the form of certificate or the equivalent (b) School in the form of letter. (4) Name of Hospital : School Address (d) Name of Hospital : School Address (e) Phone # of Hospital (f) No. of Patient/C i st patient/number of Cases (g) Medical Practice Name/Abbr. (h) Date of establishment (i) Medical Faculty Name (j) Date of establishment (5) State or other Zone (6) Country, which the Medical Institu tion is situated in : (7) Names and address of the person from whom admission is desired (a) Full name (b) Middle name (i) Date of birth (c) Email Address