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Akt MRCGP 2019 Application Form

This document is an application form for the MRCGP [INT] South Asia examination. It requests personal information such as name, address, contact details, medical education and training history. It asks the applicant to choose an examination center and state which eligibility criterion they meet to sit for the exam. The last section requires the applicant's signature to agree to abide by exam rules and regulations. Upon approval, the form is signed by an official reviewer.

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Vijay Mg
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241 views3 pages

Akt MRCGP 2019 Application Form

This document is an application form for the MRCGP [INT] South Asia examination. It requests personal information such as name, address, contact details, medical education and training history. It asks the applicant to choose an examination center and state which eligibility criterion they meet to sit for the exam. The last section requires the applicant's signature to agree to abide by exam rules and regulations. Upon approval, the form is signed by an official reviewer.

Uploaded by

Vijay Mg
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
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Staple here

MRCGP [INT] SOUTH ASIA ONE


recent
passport-
size photo
APPLICATION FORM
for Part 1 Examination
Please fill in either electronically or legibly by hand in block letters
and send with the correct application fee (as below)
to an MRCGP[INT]-accredited body in South Asia or to the South Asia Secretariat
(see the Application Guide).

PERSONAL AND CONTACT INFORMATION


1. Candidate ID number:
(If you do not have a 7-digit candidate ID number, a new ID number will be assigned
to you and sent to you by email. Please make a note of it and quote in on your exam
papers and in all correspondence.)
2. Last Name (surname):

3. Usual Forename(s):

4. Full name as you would


like it to appear on
record
5. Residential address:
(house no. and street or P.O.Box)
(district)
(city)
(province/region)
(country)
6. Other contact details:
Home telephone: +( )
(in full international format)
(country code, region/city code, tel.no.)
Work telephone: +( )
(in full international format)
(country code, region/city code, tel.no.)
E-mail:
(Please enter CLEARLY a valid personal email address that you regularly check, as most
correspondence and important announcements are communicated to candidates by email).

MRCGP [INT] EXAMINATION HISTORY


7. Dates of all Part 1 exams
taken previously:
(dd/mm/yyyy)

MRCGP [INT] South Asia


AKT 24 | May 2019
EDUCATION AND TRAINING
8. Name and location of
Medical School
graduated from:

9. Date of qualification:

10. Country of postgraduate


clinical experience:

11. Country of ethnic origin:

12. Registration authority:

13. Registration number:

14. Date of full registration:

ELIGIBILITY
15. I am eligible to apply for the MRCGP[INT] South Asia Examination under the following criterion
– please choose at least ONE:

a. I have satisfactorily completed a structured two year training course or a two year
diploma in family medicine as recognised by the MRCGP [INT] South Asia Board
(certificates of experience and references attached).

b. I have satisfactorily completed a structured one year training programme / diploma


in family medicine as recognised by the MRCGP[INT] South Asia Board
(certificates of experience and references attached) along with a further 2 years of
clinical experience.

c. I have completed a minimum of five years of clinical experience of which a


minimum of three years has been in family medicine.

16. Please choose below the examination centre where you would like to take the Part 1 examination.
All candidates will be assigned to an examination centre of their choice.

Colombo Chennai Dhaka Jeddah Karachi Delhi Lahore

NOTE: Changing your exam centre preference is only possible in exceptional circumstances.
Requests after the registration closing deadline may not be accommodated.

MRCGP [INT] South Asia


AKT 24 | May 2019
CANDIDATE’S STATEMENT
I hereby apply to sit the MRCGP [INT] South Asia Examination, success in which will allow me to
become an International Member of the UK’s Royal College of General Practitioners. I have read
and agree to abide by the conditions set out in the MRCGP [INT] South Asia Examination Rules
and Regulations as published on the MRCGP [INT] South Asia website:
www.mrcgpintsouthasia.org
I understand that success in the two modules of the South Asia MRCGP [INT] examination does
not automatically make me an International Member of the RCGP, and that I must apply to register
with the RCGP as an International Member before I am allowed to refer to myself as “MRCGP
[INT]”.
I understand that “MRCGP [INT]” stands for “Member of the Royal College of General
Practitioners [International]” and the title is subject to remaining a Member in Good Standing,
which involves continuing annual membership subscription and adhering to the RCGP values and
philosophy.
If accepted for International Membership, I undertake to continue approved postgraduate study
while I remain in active general practice, and to uphold and promote the aims of the College to the
best of my ability.
I attach the following:
a. A photocopy of my qualification and registration documentation.
b. One passport-size photograph endorsed by your department head /
supervisor / MRCGP [INT] graduate.
c. Job experience certificates / private practice certificates etc to
prove that you fulfil the eligibility criteria.
d. A Bank Draft made payable to “MRCGP [INT] South Asia”.
Please Note: Bank draft without MICR (Magnetic Ink
Character Recognition) number will be not accepted.

Bank Account # (mandatory) ______________

Signature: _____________________

Full name: ____________________________________________________________


(Please write your name by hand)
Date: _________________________________________________________________

For official use:

Application Receiving Date: ____________________________________________________

Eligibility Criteria Met: Yes No

Application approved under Eligibility criteria: A B C

Name of the approving person: ___________________________________________________

Signature: ___________________________________ Date:_________________________

MRCGP [INT] South Asia


AKT 24 | May 2019

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