Application for registration as DNB Trainee

In the subject of _____________________________

To be filled up for registration after passing CET/PRIMARY/P.G. DIPLOMA/M.D./M.S. within one month of their joining as a DNB TRAINEE

(For Office Use Only)

National Board of Examinations

(Ministry of Health & Family Welfare, Govt. of India)

Ansari Nagar, Mahatma Gandhi Marg, (Ring Road), New Delhi – 110 029

 

1.         Name __________________________________________________________________

2.         Father’s/Husband’s Name __________________________________________________

3.         MCI Reg. No.     _________________________

            Date of Reg.         _________________________     State __________________________

4.         Date of Birth         _________________________

5.

Category:

General

SC

ST

OBC

 

6.         Correspondence Address

            Street                  __________________________________________________________

            City                     __________________________ State ___________________________

            Country               __________________________ Pin ____________________________

            Phone (Office)   __________________________ Residence _______________________

            E-mail                 __________________________ Mobile No. ______________________

7.         Permanent Address

            Street                 ___________________________________________________________

            City                    __________________________ State ____________________________

            Country              __________________________ Pin _____________________________

8.         Details of Examination Passed (Attested copies of Certificates to be attached.)

No. of Attempts

 

9.	Speciality	Broad Speciality		Super Speciality
10.	Institution	NBE Accredited		Medical College

 

11.       Name of Institution _______________________________________________________

 

12.       Date of Registration with Institution as a DNB Trainee w.e.f. from

 

            Day _____ Month_____Year __________  to Day _____ Month _____ Year__________

 

13.       Duration of P.G. Diploma w.e.f.

 

            Day _____ Month_____Year __________  to Day _____ Month _____ Year__________

 

14.       Topic of thesis

 

 

 

 

 

                  (Protocol is to be submitted within 3 months of joining the Institution.)

 

15.       Please tick if logbook is maintained.                             

           

 

 

 

 

___________________                                                               ___________________________

Signature of Candidate                                                        Signature of Head of Department

                                                                                                      (With Department Seal)

 

 

 

__________________________________

Counter signed by the Head of Institution

(With Institution Seal)

 

Encls.:

1.         CET-NBE/Primary Passed Certificate.

2.         P.G. Diploma Pass Certificate.

3.         Certificate of training to be undergone in the required format.

4.         P.G. Degree training Certificate.

Note: To avoid delay in registration of candidates, please ensure that the form/s is/are complete in all respects.

 

 

 

 

 

 

format of certificates

The certificate must be issued on official letter head only.

Incomplete Information may lead to rejection of registration.

 

Certificates to be issued by NBE accredited institutions

 

Format No. – 1

 

(Certificate of CET-NBE/Primary Pass Candidates in Broad Specialities)

 

Certified that Dr. ____________________________________ who has passed his/her CET/Primary examination of the Board has been selected as a DNB trainee and has been working in the department of ______________________ w.e.f. day _____ month ______ year __________ for a period of 3 years against the seat recognized by the Board vide its letter No. ________________________dated _____________ valid up to ______________ (month & year).

 

He/she will be maintaining Log Book. He/She will be writing Thesis under Dr. ___________________. He/she will be completing his/her training on day _____ month _____ year __________ .

 

 

Signature of the head of the department                      signature of the head of the institution

          (With Seal and Date)                                                        (With Seal and Date)   

********************

 

FORMAT NO. – 2

 

 (Certificate of Diploma Pass Candidates in Broad Specialities)

 

Certified that Dr. ___________________________ has been appointed as registrar/Sr. resident/tutor on a teaching post in the subject of ______________________, after passing diploma of 2 years in the same subject, and will work as a DNB trainee for a period of 2 years w.e.f. day _____ month _____ year _________. The above department is recognized by NBE vide its letter No. _________________________ dated __________ valid up to __________ (month & year).

 

Certified that he/she is writing thesis under Dr. ____________________________ who is an approved postgraduate teacher  by  MCI/University/NBE. He/she  will  be maintaining  log  book. This  hospital/institution  has  selected Dr. __________________________ as a CET/Primary passed candidate to whom the diploma candidate will impart training.

 

He/she will be completing his/her training on day _____ month _____ year _________ .

 

 

Signature of the head of the department                     signature of the head of the institution

                      (With Seal and Date)                                                       (With Seal and Date)   

********************

 

format No. – 3

 

(Certificate for MD/MS/DNB pass candidates in Super Speciality)

 

Certified that Dr. ______________________________ has been selected as a DNB candidate for training in the subject of __________________, after passing MD/MS/DNB, for a period of 3 years w.e.f. day _____ month _____ year ______ in the above subject which is recognized for DNB training by NBE under Dr. ____________________

against the seat recognized by Board vide its letter No. _______________dated _________ valid upto ___________

(month and year).

 

He/she has written thesis/dissertation during his/her MD/MS/DNB degree examination.

 

He/she will be maintaining log book. He/she will be completing his/her training on day ____ month ___ year _____.

 

 

Signature of the head of the department                      signature of the head of the institution

        (With Seal and Date)                                                         (With Seal and Date)   

********************
Certificates to be issued by medical colleges

 

Format No. – 4

 

(Certificate of CET-NBE/Primary Pass Candidates in Board Specialities)

 

Certified that Dr. ____________________________ has been selected as a DNB trainee, after passing CET/Primary Examination, in the subject of ___________ w.e.f. day _____ month ______ year ________ . The above department is recognized by M.C.I./University for MD/MS training. He has been working under Dr.___________________________ who is declared/approved postgraduate teacher by the University/MCI maintaining student teacher ratio of 1:1 (i.e. the above teacher has taken only one postgraduate candidate for training for the Board’s examination and that no MD/MS candidate of the University has been registered under the above teacher during the admission year). He/she will be maintaining Log Book and will be writing thesis/dissertation on __________________ under the above teacher.

 

He/she will be completing his/her training on day _____ month _____ year __________ .

 

 

Signature of the Head of the department                 signature of the head of the institution

             (with seal and date)                                                                                 (with seal and date)

********************

 

format No. – 5

 

(Certificate of Diploma Pass Candidate in Board Specialities)

 

Certified that Dr. __________________________________ has been working in the department of _________________________ as Registrar/Sr. Resident/Tutor on a paid teaching post and has been selected as a DNB candidate for a period of two years w.e.f. day _____ month ______ year __________, after passing diploma of two years in the same subject.

 

The above department is recognized by MCI/University for training of MD/MS Candidates. He/she will be working with full clinical responsibilities as that are 2^nd & 3^rd year resident as required for MD/MS trainees.

 

He/she has been writing thesis under Dr. ____________________________ who is an approved postgraduate teacher by MCI/University by maintaining student to teacher ratio of 1:1 (i.e. the above teacher has taken only postgraduate candidate for Board’s examinations and that no MD/MS candidate of the University has been registered under the above teacher during the admission year).

 

He/she will be maintaining Log Book. He will be completing his training on ___________ .

 

 

Signature of the head of the department                 signature of the head of the institution

            (With Seal and Date)                                                                            (With Seal and Date)             

********************

 

Format No. – 6

 

(Certificate for MD/MS pass candidates in Super Speciality)

 

Certified that Dr. __________________________ has been selected as a DNB candidate for training in the subject of __________________ for a period of three years w.e.f. _________, after passing MD/MS/DNB in the subject of __________________, recognized by the MCI/University. The above department is recognized for DM/MCh training. He/she will be getting training under Dr. __________________ who is a declared/approved post doctoral teacher of the University maintaining student teacher ratio of 1:1 (i.e. the above teacher  has taken only one postdoctoral candidate for training for the Board’s examination and that no DM/MCh candidate of the University has been registered under the above teacher during the admission year).

 

He/she has already written thesis during his MD/MS/DNB examination.

 

 

Signature of the head of the department                      signature of the head of the institution

             (With Seal and Date)                                                                                 (With Seal and Date)       

********************