Form-MCI-01

M EDICAL COUNCIL OF INDI A

Po cket - 14, Secto r - 8, Ph ase-I , Dw arka, N ew Del h i – 110 077
Ph o n e : 011-25367 033, 2 536 703 5, 253 670 36
Emai l : el i g ib i l i ty@mci in d i a.o rg , Web si te : w ww . mci i nd i a. o rg

APPLICATION FORM FOR ELIGIBILITY CERTIFICATE

(For getting admission to Graduate Medical Course in a Affix Attested

Foreign Medical Institution u/s 12 and 13(4B) of Indian Passport Size
Colour Photograph
Medical Council Act, 1956)

(1) Name of applicant (in Capital letters according to 12th Class Certificate or its equivalent)

….……………..…………………………………………………………………………………………………..

(2) Father’s Name ……………………………………….……………..………………………………………………

(3) Sex (tick mark the correct box) MALE FEMALE

(4) Nationality ……………………………………… Date of Birth ………………………………………………….

(5) Age (as on 31st Dec. of admission year) YEARS MONTHS DAYS

(6) Category (General/SC/ST/OBC) …….………..…………..…………………….………………………………

(7) Two visible identification marks : (a) ……..………………..……………………………………………………

(b)……………………………………...……..………………….………………………………….…..……………

(8) Present Address in capital letters (including pin code no & phone no) ………………………………………

……………..…..………………………………….…………………………………………………………………

……………..…..………………………………….…………………………………………………………….……

(9) Permanent Address in capital letters (including pin code no. & phone no.) ………..…………….…………

…………………………………………………………………………………………………………..……….……

……………………………………………………………………………………………………………….……….

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 Form-MCI-01

(10) Details of educational qualifications from 11th standard onwards:

11th Class details :

 School Name & Address …………………………...……………..…………………………………………..

 Board Name & Address ……………………………………….………………………………………………
 Roll No…….………….………………………………. Result………………………………………………..
 Certificate No. & Date ……………………………………………………………..…………………………
 Date of Joining & Date of Completion.……………………………………………………………………..
Subjects Maximum Marks Marks Obtained % Result
Theory Practical Theory Practical Pass/Fail
English
Physics
Chemistry
Biology
PCB Total

12th Class/ Intermediate or 10+2 details :

 School Name & Address …………………………...……………..…………………………………………..

 Board……………………………………….…………………………Roll No…….………….………………
 Date of Joining …………….…..……………. ……………..Date of Passing …..…………………………
 School Code No. ……………………….……………………………………………………………………..
Subjects Maximum Marks Marks Obtained % Result
Theory Practical Theory Practical Pass/Fail
English
Physics
Chemistry
Biology
PCB Total

B.Sc. or any other University Examination. (if any) :

 College Name & Address ……………………………….………………………………...………………..…

 University ….…………………………………………………………………………………………………….
……….……………………………….………………………Roll No…….…………...…….……………….…
 Date of Joining ..………………………..…. Date of Passing …..………………………………..…………
Subjects Maximum Marks Marks Obtained % Result Pass/Fail
Theory Practical Theory Practical

Grand Total

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 Form-MCI-01

(11) Name of the Foreign Medical College/Institution wherein Admission Is sought by the

Candidate……………………………………...…………………………………….………………………………

………………………………………………………………………………………...………………………………

(12) Transfer/Migration, if any with the name of present Medical College/Institution along with date of

Transfer/Migration (attach supportive documents)…….…………………………………………………….

(13) Name of the Foreign Medical University to which the Foreign Medical College/Institution with country

name mentioned in Col. No. 11 above, is affiliated ………………………………………………….…………

…………………………...…………………………..…..…………….……………………………..………………

(14) Year of admission in Foreign Medical College/Institution ……………………..…………………..…………..

(15) Details of payment of fees :

(a) Eligibility Certificate Fee:

(i) Paid by Demand Draft of Rs. 2,000.00 (Rs. Two thousand only)
DD
(ii) Demand draft, details thereof :

Name and address of issuing bank…………………………………………………………………

Demand Draft Number and date ……………………………………………………………………
Amount Rs……………………………………………………………………………......................

(b) Verification Fees (as prescribed by concerned board) Details:

(i) Name & Address of issuing bank…………………………………………………………………….

(ii) Demand Draft Number and date …...……………………………………………………………….
(iii) Demand Draft in Favour of …………………………………………………………………………..
(iv) Amount Rs…………………………………………………………………………………….............

(16) Email address of the candidate (in capital letters): …………….……………………………………………….

(17) Mobile No of the Candidate………………………………………………………………………………………..

(18) (a) Aadhar No …………………………………………….

(b) Voter Identity Card No…………………………………

(19) Passport details:

(a) Passport No…………………………………………….

(b) Date and Place of issue……………………………….

(c) Date of Expiry…………………………………………..

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 Form-MCI-01

(20) (a) Whether any application has been made by you earlier for grant of Eligibility Certificate to the
Council – - Yes/No.

(b) If yes, state whether such application was accepted or rejected and provide details of the
communication made by the Council. (Annexure copies of such communication)

(Signature of Candidate)
Place : …………………..

Date : …………………..

NOTE: THE APPLICANT MUST PROVIDE HIS/HER EMAIL ADDRESS AND MOBILE NO. THE CERTIFICATES
OF THE CANDIDATES WILL BE MADE AVAILABLE ONLINE ON OUR WEBSITE www.mciindia.org ON OR
AFTER 27th FEBRUARY,2013 UNDER “APPLY ONLINE PORTAL”. A LOGIN ID AND PASSWORD WILL BE
PROVIDED TO THE APPLICANTS THROUGH SMS AND E-MAIL BY WHICH THEY CAN DOWNLOAD THEIR
CERTIFICATES AND CAN TAKE PRINT OUT.

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 Form-MCI-01

DECLARATION

I declare that the entries made by me in this Form are true to my knowledge and I
understand that I am liable for action under the law for any false information or document
produced by me without any notice from MCI, New Delhi.

I also understand that the Medical Council of India shall be free to investigate on its own into
the correctness of information furnished by me in this application and/or call for any further
information in this regard from me and in the event of any information furnished by me being
found to be incorrect or false during such investigation or at any subsequent stage, the Council
may refuse to issue the eligibility certificate or if already issued may cancel the same and I shall
stand debarred from appearing in the Screening Test prescribed in Sub-Section(4A) of Section 13
of the Indian Medical Council Act, 1956 and any other rule and regulation framed by MCI, New
Delhi without any notice.

I understand that after obtaining the foreign recognized primary medical qualification, and
subject to the verification as contained above, I have to pass a screening test prescribed under
the Indian Medical Council Act, 1956 read with the Eligibility Requirement for taking Admission
in an Undergraduate Medical Course in a Foreign Medical Institution Regulations, 2002 and the
Screening Test Regulations, 2002 before grant of provisional/permanent registration by the
Medical Council of India or any of the State Medical Councils. I further understand that the
primary medical qualification has to be confirmed by the Indian Embassy concerned to be a
recognized medical qualification for enrolment as medical practitioner in the country in which
the institution awarding the said qualification is situated. In case on confirmation from the
Indian Embassy/High Commission of India concerned, it found that the primary medical
qualification awarded to me by the university/institution concerned is not recognized/approved
for enrolment as medical practitioner in that country, the Medical Council of India may reject my
application at any time.

(Signature of Candidate)

Name……………….………........

Place : …………………..
Date : …………………..

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 Form-MCI-01

CHECK LIST
(for submission of documents)

The candidates are required to ensure that the documents be enclosed as per the order in the
Checklist. All papers/documents should be numbered and arranged according to the checklist in the following
order & tick mark the relevant box:

S.NO. Particulars/Details Whether

Yes or No
1 A Bank Draft for Rs.2,000/- in favour of “The Secretary, Medical Council of India, New Delhi” Yes No

2 Whether candidate’s name, Father’s name, phone no. & purpose of application has been Yes No
written on the reverse side of DD/Pay order.
3 Application form in original Yes No
4 Three self attested copies of Passport along with copy of complete visas mentioned on passport, if Yes No
admission already taken.
5 Proof of Nationality or Overseas Citizen of India. Yes No
th
6 Three self attested copies of Pass Certificate as well as Mark sheet of 10 Class or equivalent Board Yes No
examination along with copy of Transfer Certificate/Migration Certificate in case change of School.
7 Three self attested copies of Pass Certificate as well as Marksheet of 11th Class or equivalent Yes No
examination along with copy of Transfer Certificate/Migration Certificate in case change of School.
8 Three self attested copies of Mark sheet of 12th Class (10+2) or equivalent Board examination and Yes No
also copy of Transfer Certificate/Migration Certificate in case change of School/Board.
9 Three self attested copies of Pass Certificate of 12th Class (10+2) or equivalent Yes No
examination.(showing all the subjects & the name of the school)
10 Three self attested copies of School/College Leaving Certificate for Bihar Board & Tamilnadu Board Yes No
Students.
11 Equivalency Certificate from Association of Indian Universities (AIU), New Delhi for the +2 equivalent Yes No
qualifications, if obtained from abroad along with subject wise equivalency. If marks are given in
grades, proof of their equivalent percentage of marks.

12 Three self attested copies of B.Sc. Mark sheet - if the candidate obtained less Yes No
than 50% marks for General and 40% marks for Reserve Category
13 Three self attested copies of OBC/SC/ST Certificate Yes No
(mention the Caste Certificate number, date and name and address of the Issuing authority on the
back side of copy of the certificate )
14 Three self attested copies of English Translation of OBC/SC/ST Certificate - Yes No
(if the Certificate is in Regional language) .
15 One additional colour passport size photograph with front view Yes No
16 Three attested copies of Admission/Acceptance letter issued by concerned Foreign Medical Yes No
University
17 Year wise mark sheet of MBBS or equivalent course from 1st year onwards, if already taken Yes No
admission and /or completed the course then copy of degree along with complete marksheet of
MBBS is required.
18 Copy of student ID card issued by the concerned medical university/institute, if admission already Yes No
taken
19 Additional DD for Verification of 10+2 mark sheet/Certificate, as per list attached with the application Yes No
form.

20 Original Certificates for Serial No 5 to Sr. No 14 for verification. Yes No

21 Affidavit on Rs.10/- stamp paper duly notarized. Yes No

Dated …………………………

(Signature of Candidate)

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 Form-MCI-01

M EDICAL COUNCIL OF INDI A

Po cket - 14, Secto r - 8, Ph ase-I , Dw arka, N ew Del h i - 110 077
Ph o n e : 011-25367 033, 2 536 703 5, 253 670 36
Emai l : el i gi bi li t y@m cii ndi a. org, Web si te : ww w . mci i nd i a. o rg

T HREE NON-ATTESTED
PHOTOGRAPH SPECIMEN SIGNAT URE OF
T HE CANDIDAT E

Colour Photograph

(Signature of the Candidate)

Colour Photograph

(Signature of the Candidate)

Colour Photograph

(Signature of the Candidate)

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 Form-MCI-01

INSTRUCTIONS
(Read Instructions carefully before filling up the Eligibility

1) Incomplete documents and applications without originals will not be accepted. Application
must be complete in all respects. No alteration will be allowed to be made in the application
form after it has been submitted to the Council.

2) The applicant who applies through post must enclose the original certificates properly
tagged along with the application form. The same will be returned after issuance of Eligibility
Certificate.

3) The Form should be filled up using Capital letters in candidate’s own legible handwriting.

4) Demand draft for Rs.2000/- (Rupees Two Thousand only) in favour of “The Secretary,
Medical Council of India”, Payable at New Delhi. On reverse of demand draft please
mention applicant’s Name, Father’s Name, purpose for which the draft submitted and
Telephone Number. Applicant is required to affix one recent front view colour photograph
on the application form.

5) All the documents should be submitted in original (along with three legible self attested
photocopies)

6) Original Matriculation Certificate showing Date of Birth (with three self attested photocopies.)

7) Original Marksheet of the 11th class (with three self attested photocopies).

8) Original +2 Marksheet & Pass Certificate (with three self attested photocopies).

9) Original and three attested copies of School/College Leaving Certificate for Bihar Board and
Tamilnadu Board Students.

10) Original SC/ST/OBC Certificate (with three attested photocopies) (in case of reserved
category candidates) and a copy of English Version in case of Caste Certificate is in regional
language.

11) Original Proof of Admission in Foreign Medical University (alongwith three self attested
photocopies)

12) Applicant to retain one copy of application form and draft for future reference.

13) Equivalency Certificate from AIU to the +2 equivalent qualifications, if obtained from abroad.

14) Fee for verification of qualifying examination as prescribed by the State Boards/Universities
concerned, as mentioned below in Column No. 16.

15) Eligibility Certificate is issued only through email and no hard copy is issued. Therefore,
candidates must have a valid email ID on which the Eligibility Certificate to be sent.

16) Verification fees to be submitted by way of DD/Pay Order by the candidate who have
qualified 10+2 examinations from the following States :

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 Form-MCI-01

VERIFICATION FEE WILL BE SUBMITTED ONLY IN FORM OF DEMAND DRAFT/PAY ORDER

SNo State/Board Amount In favour of

a) Andhra Pradesh Rs. 100/- Secretary, B.I.E, AP, Hyderabad
b) Assam Rs.100/- Secretary, Assam Higher Secondary Education, Council
payable at Guwahati
Secretary, C.B.S.E., payable in respect of
12th Roll Number starting with : -

‘1’ Payable at Ajmer for Rs. 235/-

‘2’ Payable at Panchkula for Rs. 540/-
c) CBSE ‘3’ Payable at Guwhati, for Rs. 200/-
‘4’ Payable at Chennai for Rs. 240/-
‘5’ Payable at Allahabad for Rs. 130/-
‘5’ Payable at Dehradun for Rs. 540/-
‘6’ Payable at Delhi for Rs. 100/-
‘7’ Payable at Bihar for Rs. 200/-
d) GOA Rs.100/- Secretary, Goa Board of Secondary & Higher Secondary
Education, Alto-Betim-Goa.
Secretary, Gujarat Secondary & Higher Secondary
e) Gujarat Rs.225/- Education Board, Gandhinagar payable at
Ahmedabad/Gandhinagar from Nationalized bank only.
f) ICSE Rs.300/- Secretary, Council for the Indian School Certificate
Examination, payable at Delhi.
Jammu & Chairman J & K State Board of School Education,
g) Rs.590/- payable at J & K Bank, Rehari Colony, Jammu/Lalmandi
Kashmir
Srinagar.
h) Jharkhand Rs.100/- Jharkhand Academic Council Fund, Payable at Ranchi
Rs.200/- Secretary, Madhya Pradesh Board of Secondary
i) Madhya Pradesh Education, payable at Bhopal
Rs.300/-
(Rs. 200/- for upto 10 years and Rs. 300/- for more than 10 years)
j) Himachal Pradesh Rs.600/- Secretary, Himachal Pradesh School Education Board,
Dharamshala-176700, Payable at Dharamshala
Rs.200/- Divisional Secretary, M.S. Board of Secondary & Higher
k) Maharashtra Secondary Education of respective Divisional Board from
Rs.300/-
Nationalised Bank only. (Rs.300 for Kolhapur Divisional Board)
l) Manipur Rs.100/- Secretary, Council of Higher Secondary Education,
payable at Manipur
m) Orissa Rs.100/- “Finance Officer, CHSE, Odisha, Bhubaneswar”.
n) Punjab Rs.600/- Secretary, Punjab School Education Board, payable at
Mohali/Chandiargh
o) Tamil Nadu Rs.50/- The Director, Directorate of Govt. Examinations,Chennai-
6, payable at Chennai (From Nationalized Bank.)
Rs.100/- West Bengal Council of Higher Secondary Education,
p) West Bengal
(from SBI) Payable at Kolkata

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 Form-MCI-01

FORMAT FOR AFFIDAVIT

(ON RS. 10 STAMP PAPER DULY NOTARIZED)

I _________________________ S/D/o ______________________ resident of

_________________________________________ do hereby solemnly affirm and declare that:-

1. I have done my 10th class from _________(Name of School & Board) in the year
____________and as per my 10th class records, my date of birth is _______________.
2. I have studied 11th class with the subjects of
______________________________________in_____(Name of School/Board)_____ in the
year ______________ and declared “PASS”.
3. I have studied my 12th class with the subjects of___________________________ from -
_____________(Name of the School)_______________ in the year________________.
4. I have been granted 12th class passing certificate by the _____________ (Name of
Board)___________________.
5. I have/had joined MBBS/equivalent medical course at _____________(Name of
University/Medical College/Location/Country)_______________ in the academic year
____________.
6. I am still pursuing my Medicine course at the same University/Medical College.
7. I have completed my MBBS or equivalent medical course from _____________________
(Name of the University/Medical College) in the year ________.

DEPONENT
VERIFICATION :
I ___________________ do hereby solemnly affirm and declare that the above
statement given is true and correct to the best of my knowledge and belief and that nothing
has been concealed therefrom.

DEPONENT

Note: Strike out which is not applicable.

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 Form-MCI-01

M EDICAL COUNCIL OF INDI A

Po cket - 14, Secto r - 8, Ph ase-I , Dw arka, N ew Del h i - 110 077
Ph o n e : 011-25367 033, 2 536 703 5, 253 670 36
Emai l : el i gi bi li t y@m cii ndi a. org, Web si te : ww w . mci i nd i a. o rg

ACKNOWLEDGEMENT
(to be filled by the candidate)

Received Application from Mr./Ms.…………………………………………………………………

D/o / S/o Sh……………...………………………………………......... alongwith Bank Draft

No…………………………… dated..………………………….. for Rs 2000/- (Rs. Two thousand

only) Drawn on Bank………………………………………………………………………, who is

desirous to take/ has taken admission in MBBS or equivalent medical course at

…………………………………………………………………………………………………………….

in the year ………….for the purposes of issuance of Eligibility Certificate in terms of Clause

4(2) of the Screening Test Regulations, 2002, for consideration.

Note: The application is accepted subject to the fulfillment of requirements for issuance of
Eligibility Certificate as laid down in the MCI Regulations.

OFFICIAL Signature of Receiving Official

SE AL
with date

Email of Eligibility Section : [email protected]

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