Free Application Form for Eligibility Certificate Form - PDF Template

Indian Medical Council Act, 1956 u/s 12 and 13(4B) mandates filing the Application Form for Eligibility Certificate for students who seek admission Graduate Medical Course in Foreign Medical Institution.

Each eligible student with admission/acceptance letter by the Foreign Medical University must submit original documents along with the copies and filing fees as prescribed in MCI-01 form. You must attach attested color photograph. Please complete pages comprising of checklist, specimen signatures, declaration, and acknowledgement carefully. In addition, please fill this form in block capital letters by hand legibly. The schedule for verification fee is enclosed in MCI-01 form. Please select your state and prepare the DD for remitting verification fee accordingly.

Application Form for Eligibility Certificate

Steps To Prepare Application Form for Eligibility Certificate

Part I – Personal and Educational Details

Attach colored passport sized attested photograph.
Enter your name and father’s name on line 1 and 2 respectively.
Select your gender.
Enter your nationality and date of birth on line 4.
Enter your age in the required format on line 5.
Specify which category you belong to.
Enter two identification marks in 7a and 7b respectively.
Enter your present address, pin code, and phone number on line 8.
Enter your permanent address, pin code, and phone number on line 9.
Line 10 requires details of educational qualification. Enter details for 11th class, 12th Class/ Intermediate or 10+2 class, and B.Sc. or any other University Examination in the required format. Please fill all applicable details or leave blank otherwise.
Enter the name of the foreign university/institution on line 11.
Proceed by providing the name of the affiliate institution in India on line 12.
Enter the year of the admission in the Foreign Medical University/Institution on the next line.
Enter particulars of Eligibility Certificate Fee in 14a. Then provide details of the verification fees in 14b.
Enter your email address on line 15. Enter your mobile phone number on line 16. Entering details on line 15 and 16 is necessary to receive login ID and password for online access to Eligibility Certificate.
Please enter date, place, and sign in the box provided for the same.

Part II – Declaration

Enter date, name of the place, your name, and sign in the box to complete part II, Declaration.

Part III – Checklist

Complete documentation as required in the format prescribed in the checklist in option 1 through 17. Enter date and sign in the box provided.

Part IV – Specimen Signature

Please affix three passport sized non-attested photographs and sign three times to submit your specimen signatures in MCI-01 Application Form for Eligibility Certificate.

Part V – Acknowledgement

The student applying for Eligibility Certificate must enter the details like his/her name along with father’s name, bank draft receipt number, bank draft date, and name of the bank on the respective lines.