Personal

Personal Details
Details

Application
Application ID
ID
PG25009227
Candidate's
Candidate's Nam
Nam Date
Date of
of Birth
Birth Gender
Gender
ee 03/Sep/1999 Male
PATEL UMANG CHAN Nationality
Nationality Mother
Mother's 's Name
Name
DUBHAI INDIAN PATEL JYOTSNABEN C
HANDUBHAI
Father
Father's
's Name
Name Religion
Religion Category
Category
PATEL CHANDUBHAI HINDU GENERAL
KANJIBHAI
Do
Do you
you belong
belong to
to Place
Place Of
Of Birth
Birth
Economically
Economically We We AKHIYANA SURENDR
ANAGAR
aker
aker Section
Section (EW
(EW
S)
S) ?? Are
Are you
you aa Person
Person
NO with
with Benchmark
Benchmark
Disability
Disability (PwD)
(PwD) ii
n
n terms
terms ofof RPwD
RPwD
Act,
Act, 2016?
2016?
NO
Are
Are You
You Willing
Willing tt
oo Take
Take up
up Post
Post Gr
Gr
aduate
aduate Courses
Courses ii
nn Armed
Armed Forces
Forces
Medical
Medical Services
Services
Institutions
Institutions
NO

Contact
Contact Details
Details

Mobile
Mobile No
No Email
Email ID
ID
+91 8264064680 umangpatel45612
3@gmail.com

Identification
Identification Details
Details

Do
Do you
you have
have Gov
Gov Government
Government of of In
In Do
Do you
you have
have Gov
Gov
ernment
ernment ofof India
India dia
dia Issued
Issued VOTER
VOTER ernment
ernment of
of India
India
issued
issued VOTER
VOTER ID
ID ID
ID CARD
CARD Number
Number issued
issued PAN
PAN CARD
CARD
CARD
CARD ?? AFH2895514 ??
YES YES
Government
Government ofof In
In Do
Do you
you have
have Gov
Gov Government
Government of of In
In
dia
dia Issued
Issued PAN
PAN CC ernment
ernment ofof India
India dia
dia Issued
Issued DRIVI
DRIVI
ARD
ARD Number
Number issued
issued DRIVING
DRIVING LL NG
NG LICENSE
LICENSE Num
Num
EPOPP4759A ICENSE
ICENSE ?? ber
ber
YES GJ2720160006179
Driving
Driving License
License V
V Do
Do you
you have
have Gov
Gov Government
Government ofof In
In
alidity
alidity ernment
ernment of
of India
India dia
dia Issued
Issued PASSP
PASSP
04/2036 issued
issued PASSPORT
PASSPORT ORT
ORT Number
Number
?? R2996684
YES PASSPORT
PASSPORT Validit
Validit
yy
08/2027
Mark
Mark ofof Identific
Identific Mark
Mark ofof Identific
Identific
ation
ation 11 (on
(on face)
face) ation
ation 22 (Birth
(Birth ma
ma
MOLE ON LEFT JAW rk/Body
rk/Body mark)
mark)
BLACK MARK AROUN
D LEFT WRIST

Correspondence
Correspondence Address
Address

Address
Address Line
Line 11 Address
Address Line
Line 22 Country
Country
56 , NEW SANSKAR TI ARBUDANAGAR , OD INDIA
RTH SOC. HAV
State
State
GUJARAT
City/District
City/District Pin
Pin Code
Code Is
Is Permanent
Permanent Ad
Ad
Ahmedabad 382415 dress
dress Same
Same as
as Co
Co
rrespondence
rrespondence ad
ad
dress?
dress?
YES

Permanent
Permanent Address
Address

Address
Address Line
Line 11 Address
Address Line
Line 22 Country
Country
56 , NEW SANSKAR TI ARBUDANAGAR , OD INDIA
RTH SOC. HAV
State
State
GUJARAT
City/District
City/District Pin
Pin Code
Code
Ahmedabad 382415

MBBS
MBBS Qualification
Qualification Details
Details

Country
Country ofof compl
compl State/UT
State/UT of
of Comp
Comp City
City
etion
etion of
of MBBS
MBBS QuQu letion
letion OTHERS
alification
alification OTHERS Other
Other City
City
Russian Federation SMOLENSK
University
University of
of Co
Co University
University Name
Name Name
Name of
of College
College
mpletion
mpletion SMOLENSK STATE ME OTHERS
OTHERS DICAL UNIVERSITY
Other
Other Name
Name ofof CC
ollege
ollege
SMOLENSK STATE ME
DICAL UNIVERSITY
Month
Month and
and Year
Year
of
of Passing
Passing
16/06/2023

Internship
Internship Details
Details
Have
Have you
you comple
comple City
City of
of Internshi
Internshi Institute
Institute of
of Inter
Inter
ted
ted Internship
Internship pp nship
nship
NO KALOL SWAMINARAYAN INS
TITUTE OF MEDICAL
SCIENCE AND RESEA
RCH
Date
Date of
of start
start of
of II Likely
Likely Date
Date ofof co
co
nternship
nternship mpletion
mpletion ofof Inter
Inter
27/05/2024 nship
nship
26/05/2025

Medical
Medical Council
Council Registration
Registration Details
Details

Medical
Medical Council
Council Medical
Medical Council
Council Name
Name ofof Medical
Medical
Registration
Registration Typ
Typ Registration
Registration Nu
Nu Council
Council
ee mber
mber GUJARAT MEDICAL C
PROVISIONAL GPR75814 OUNCIL

FMG
FMG EXAMINATION
EXAMINATION MARKS
MARKS

Note
Note :: Wrong entry of percentage of MBBS marks will invite action a
s deemed fit by NBEMS including but not limited to cancellation of th
e candidature.The marks shall be provided as an accurate value roun
ded down to two decimals. An illustration to this process is as follow
s: -

Cand
Cand Maximu
Maximu Marks
Marks OO Aggregate
Aggregate PP Percentage
Percentage to
to be
be ro
ro
idate
idate m
m Mark
Mark btained
btained ercentage
ercentage unded
unded down
down to
to
ss

A 900 900 69.22222 69.22

B 900 619 68.77777 68.77

For detailed clarification kindly refer Chapter 10 - 10.10.1-G

Marks
Marks obtained
obtained ii FMGE
FMGE Roll
Roll Numb
Numb
nn Foreign
Foreign Medica
Medica er
er
ll Graduate
Graduate Exami
Exami 2311208198
nation
nation (FMGE)/
(FMGE)/ SS
creening
creening Test
Test con
con
ducted
ducted byby NBEM
NBEM
S.
S. (Out
(Out of
of 300).
300).
185

Additional
Additional Information
Information

Deported/Rustic
Deported/Rustic Charged
Charged of
of use
use of
of Have
Have you
you appear
appear
ated
ated during
during Medi
Medi unfair
unfair means
means by
by ed
ed in
in NEET
NEET PG
PG pr
pr
cal
cal Course
Course NBEMS/Other
NBEMS/Other exex eviously?
eviously?
NO amination
amination body
body ?? NO
 NO

Test
Test Center
Center Details
Details

State
State City
City
GUJARAT AHMEDABAD/GAND
HINAGAR

Payment
Payment Details
Details

Amount
Amount Payment
Payment Status
Status Payment
Payment Transac
Transac
3500 Payment Success tion
tion No.
No.
5672797881045

Document
Document Upload
Upload Details
Details

Captured Photo Uploaded Photo Signature

Left Thumb Impressi

on
NEET
NEET PG PG is
is aa proprietary
proprietary examination
examination and and isis conducted
conducted by by the
the
To view
National valid
National BoardMedical
Board of Council registration
of Examinations
Examinations in certificate
in Medical of MBBS
Medical Sciences.
Sciences. TheQualification
conte Cli
The conte
ck
ntshere.
nts of
of this
this exam
exam are
are confidential,
confidential, proprietary
proprietary andand areare owned
owned bb
To view
yy the Documents
the National
National Appendix
Board
Board of I and/or Appendix
of Examinations
Examinations in II as per Examinations.
in Medical
Medical template: in Office
Examinations.
Memorandum
NBEMS
NBEMS explicitly (O.M.)prohibits
explicitly F.No.34-02/2015-DD-III
prohibits the
the candidate dated
candidate from
from29th August 2018repr
publishing,
publishing, (http
repr
s://cdn.digialm.com//per/g03/pub/726/EForms/image/ImageDocUpload/711
oducing
oducing or or transmitting
transmitting any any or or some
some contents
contents of of this
this exam,
exam, in in
61/0/1002361112.pdf)
whole
whole or or in
in part, inOR
part, in anyin form
any OM F. or
form No.by
or 29-6/2019-DD-III
by any
any means dated-10th
means verbal
verbal or August 2
or writte
writte
022
n, (https://cdn.digialm.com//per/g03/pub/726/EForms/image/ImageDocUpl
n, electronic
electronic or
or mechanical
mechanical or or for
for any
any purpose
purpose whatsoever.
whatsoever. NB NB
oad/71161/0/1001818871.pdf)
EMS
EMS shall
shall not
not entertain
entertain any any issued by Ministry
request
request for of Social
for sharing
sharing any
anyJustice and Empo
content
content of
of
werment,
the Govt of India
the examination
examination Click here.
including
including Answer
Answer Keys/Answer
Keys/Answer Sheets.
Sheets.

No
No content
content of
Declaration
Declaration of this
this exam
exam must
must be
be shared
shared with
with friends,
friends, acquaint
acquaint
ances
ances or
or third
third parties
parties including
including sharing
sharing through
through online
online means
means
or
or via
via social
social media.
media. Social
Social media
media includes
includes but
but not
not limited
limited to
to SS
MS,
MS, Whatsapp,
Whatsapp, Facebook,
Facebook, Twitter,
Twitter, Hangouts,
Hangouts, Blogs
Blogs etc
etc using
using ei
ei
ther
ther one’s
one’s own
own account
account or
or proxy
proxy account(s).
account(s).

By
By registering
registering for
for and
and /or
/or appearing
appearing in
in NEET
NEET PG
PG the
the candidate
candidate
explicitly
explicitly agrees
agrees to
to the
the above
above Non
Non Disclosure
Disclosure Agreement
Agreement and and gg
eneral
eneral terms
terms of
of use
use for
for NEET
NEET PG
PG as
as contained
contained in
in this
this Informati
Informati
on
on Bulletin,
Bulletin, and
and NEET
NEET PG
PG website.
website.
II certify
certify that
that II have
have physically
physically attended
attended the
the course
course of
of my
my prima
prima
ry
ry medical
medical qualification
qualification for
for the
the mandated
mandated period
period as
as per
per requir
requir
ement
ement of of the
the University
University concerned
concerned toward
toward award
award of
of my
my primar
primar
yy medical
medical qualification
qualification degree
degree certificate.
certificate.
yy medical
medical qualification
qualification degree
degree certificate.
certificate.
Violation
Violation of
of any
any act
act or
or breach
breach of
of the
the same
same shall
shall be
be liable
liable for
for pp
enal
enal action
action and
and cancellation
cancellation of
of the
the candidature
candidature at
at the
the bare
bare thr
thr
eshold.
eshold.

II understand
understand andand agree
agree that
that the
the responsibility
responsibility to
to submit
submit thethe dd
ocuments
ocuments prescribed
prescribed as as per
per information
information bulletin
bulletin solely
solely rests
rests ww
ith
ith me
me and
and II acknowledge
acknowledge that
that my
my candidature
candidature for
for NEET
NEET PGPG sh
sh
all
all be
be cancelled
cancelled for
for my
my non-submission
non-submission of of documents
documents in in the
the aa
pplication
pplication form,
form, irrespective
irrespective ofof whether
whether the
the deficiencies
deficiencies inin the
the
documents
documents were/were
were/were not
not communicated
communicated by by NBEMS
NBEMS to to me.
me.

II fully
fully understand
understand that
that in
in case
case the
the photograph
photograph and
and images
images upl
upl
oaded
oaded by by me
me in
in the
the application
application form
form are
are found
found not
not to
to be
be as
as pe
pe
rr prescribed
prescribed image
image upload
upload guidelines,
guidelines, NBEMS
NBEMS shall
shall reject
reject my
my aa
pplication
pplication and
and admit
admit card
card shall
shall not
not be
be issued.
issued.
II have
have gone
gone through
through thethe information
information bulletin
bulletin of
of NEET
NEET PG
PG and
and uu
nderstood
nderstood that
that submission
submission of of documents
documents in in previous
previous session(
session(
s)
s) of
of NEET
NEET PG,
PG, or
or issuance
issuance ofof admit
admit card
card in
in any
any previous
previous sessio
sessio
nn of
of NEET
NEET PG
PG and/or
and/or declaration
declaration ofof result
result in
in any
any previous
previous sessi
sessi
on(s)
on(s) does
does not
not confer
confer any
any rights
rights for
for eligibility
eligibility towards
towards the
the curr
curr
ent
ent session
session of
of NEET
NEET PG.
PG.

II certify
certify that
that II fulfill
fulfill the
the eligibility
eligibility requirements
requirements for for NEET
NEET PG/Sc
PG/Sc
reening
reening Test
Test and
and have
have furnished
furnished complete
complete and and correct
correct informa
informa
tion.
tion. II understand
understand thatthat any
any instances
instances of of furnishing
furnishing incorrect
incorrect in
in
formation
formation detected
detected during
during any
any stage
stage ofof the
the examination
examination proce
proce
ss
ss will
will automatically
automatically disqualify
disqualify meme from
from the
the examination
examination proce
proce
ss
ss and
and II will
will not
not bebe allowed
allowed appear
appear forfor NEET
NEET PG/Screening
PG/Screening Test
Test
in
in future.
future.

Similarly,
Similarly, if
if such
such instances
instances gogo undetected
undetected during
during the
the current
current ee
xamination
xamination process
process but,
but, are
are detected
detected in
in subsequent
subsequent years,
years, suc
suc
hh disqualification
disqualification will
will take
take place
place with
with retrospective
retrospective effect.
effect.
II also
also understand
understand thatthat providing
providing incomplete
incomplete information
information will
will aa
utomatically
utomatically disqualify
disqualify me
me from
from the
the examination
examination process.I
process.I hav
hav
ee read
read the
the information
information bulletin
bulletin and
and do
do hereby
hereby undertake
undertake that
that II
will
will not
not indulge
indulge inin any
any unfair
unfair means/practice
means/practice for
for NEET
NEET PG/Scre
PG/Scre
ening
ening Test
Test II understand
understand that
that the
the decision
decision of
of NBEMS
NBEMS shall
shall be
be fifi
nal
nal and
and binding
binding upon
upon me.
me.

Any
Any dispute
dispute concerning
concerning NEET
NEET PG PG would
would bebe subject
subject to
to Jurisdicti
Jurisdicti
on
on of of the
the Competent
Competent Courts
Courts exclusively
exclusively at at Delhi/New
Delhi/New Delhi
Delhi onl
onl
y.
y. II will
will comply
comply with
with the
the Non
Non Disclosure
Disclosure Agreement
Agreement as as indicate
indicate
dd in
in the
the information
information bulletin.
bulletin. II certify
certify that
that II have
have read
read the
the info
info
rmation
rmation bulletin
bulletin thoroughly.
thoroughly.