• Please fill the application form for long courses only.
  • Please fill the information as completely as possible.
  • Items highlighted in Red are mandatory fields.

Basic Information
Title: First Name: Middle Name: Last Name:
Gender: Marital Status: Date of Birth:
Year: Month: Date:

Contact Information
Flat / H.No.: Building Name: Plot:
Lane / Street: Colony / Locality: Area:
City / Town / Village: Landmark:
State: Country: PIN Code:
Mobile Phone (Including Country Code): Residence Telephone (Including Country Code): Email ID:
Clinic Telephone (Including Country Code): Alternate Telephone (Including Country Code): Alternate Email ID:
Photo ID Proof: ID Proof Doc. No.: Address Proof: Address Proof Doc. No.:

Educational Information
S.No. Course Type Course Name University / OrganisationType Year
1.
2.
3.
4.
5.

Medical Registration
Medical Registration Type: Medical Registration No.: Country of Registration:
Are you member of Medical Association of your country:: Name of Medical Association and Local Chapter: Medical association Registration No.:

Employment Information
S.No.: Organisation: Designation: Job Description: Years at Job:
1.
2.
3.

Course & Payment Details

Course: Payment Amount:
Amount in US $
I will Pay the fees by:
 Credit Card / Debit Card SWIFT Transfer

Visitor Survey
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Terms & Conditions:
I hereby declare that I am an MBBS/MBChB/MD Doctor registered with Medical Council in my Country and licensed to practice Modern Medicine. I have read and understood all the Terms and Conditions and Student Declaration on this website and unconditionally accept them as binding on me. I will send my Transcripts and Medical registration Certificates and pay the required fee for admission. I understand that Fee once paid will not be refunded under any circumstances. I further declare under Penalty of Perjury that the above information provided by me is true and correct in all aspects. I hereby indemnify Commonwealth Medical Evarsity and its partners against damages of any nature caused due to erroneous or falsified data submitted by me.
I agree to abide by the Terms & Conditions and Student Declaration listed on this website.