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Master in Emergency Medicine Application Form

This document is an application form for the Master in Emergency Medicine (International) program at GWU, USA. It includes instructions for filling out the form, payment details, and required documents for submission. Candidates must ensure all information is accurate and self-attested, and they are advised to keep a photocopy of the completed application for their records.

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travelogate.ashish
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7 views2 pages

Master in Emergency Medicine Application Form

This document is an application form for the Master in Emergency Medicine (International) program at GWU, USA. It includes instructions for filling out the form, payment details, and required documents for submission. Candidates must ensure all information is accurate and self-attested, and they are advised to keep a photocopy of the completed application for their records.

Uploaded by

travelogate.ashish
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Form No:

1. Affix your passport size


photograph here
(do not pin or staple)
APPLICATION FORM
2. The photograph to be
Master
ImportantinInstructions:
Emergency Medicine (International), GWU, USA affixed here SHOULD NOT be
 Please refer the prospectus before filling the form. attested.
 Use Black/Blue Ball Point Pen only.
 Do not make any stray mark on the sheet.
 Please retain the photocopy of the filled application form for further reference.
 Demand Draft of INR 1000/- should be enclosed in favor of
Max Healthcare Institute Ltd. payable at New Delhi

Please note the bank transfer details as mentioned below:


Particulars Details
Company Name Max Healthcare Institute Ltd.
Bank Name Ratnakar Bank Limited
Account No. 1347420
Bank Address Ground Floor, M-6, Hauz Khas, New Delhi- 110 016

IFSC Code RATN0000141

1. Name(In full, as appearing in MBBS certificate)

2. Father’s /Husbands Name

3. Mother’s Name

4. Date of Birth Date Month Year

5. Date of completion of Internship Date Month Year

6. Permanent Registration No.

7. Mobile No

8. Residence No

9. E-mail ID:
10. Details of Examination Passes (M.B.B.S onwards)

1. Details of Examination Passes (M.B.B.S onwards)

2. Correspondence Address:
3. List of enclosures: (All photocopied documents must be self attested)

11. Correspondence Address:

12. List of enclosures: (All photocopied documents must be self attested)


 MBBS degree certificate
 Internship completion certificate
 Permanent registration certificate
 Demand Draft of INR 1000/- should be enclosed in favor of Max Healthcare Institute Ltd. payable
at New Delhi.

Declaration

 I have read the rules and regulations of MEM (International), GWU, USA and shall abide
by them. The particulars given in the application form are true and accurate to the best
of my knowledge and belief. The documents submitted as evidence of above facts are
self attested photocopy of original documents.
 I understand that I am liable to be disqualified from the MEM (International) course, in
case of any information/document, supplied by me, are found to be false.
 I am aware that Post Graduate Masters Program in Emergency Medicine (International)
is not affiliated with, sponsored, recognized or approved by Medical Council of India
and/or the National Boards of Examination.

(Signature of the candidate)

Important Note:

Photocopy of the filled up application form must be retained by the candidate for future use.

Send your application to:

Ms. Vandana Shastri


Program Manager, Max Institute of Medical Excellence
Max Super Specialty Hospital, Saket, West Wing, B1
Contact Details: 011-40633834 (Extn:3834) Email: education@[Link]

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