SAMPLE FORM
National Academy of Medical Sciences (India)
Ansari Nagar, Ring Road
New Delhi – 110029
NOMINATION FORM FOR THE
MEMBERSHIP OF NATIONAL ACADEMY OF MEDICAL SCIENCES (INDIA) – MNAMS
Under Regulation V
I, [Name of Fellow*]
Fellow of the National Academy of Medical Sciences (India) propose herein-named candidate for
admission to the Membership of Academy – MNAMS
Name of Candidate
Present Institution/Hospital
Designation
Address:
Residence:
Tel.No.
Office:
Tel.No.
Mobile Email
PAN AADHAR
Details of DNB Examination conducted by NBE [batch passed NBE held in November, 1992 & onwards]
1. Year of Passing
2. Roll No.
3. Subject
This is to certify that I have known Dr.
for the last Years. To the best of my knowledge, he/she bears good character and is fit for
admission to the Membership of the National Academy of Medical Sciences – MNAMS.
Signature with date
Proposer
(Name in block letters)
Address
*Only Fellows of the Academy are entitled to sign the certificate
BIODATA of the candidate applying for admission to the
“Membership of the National Academy of Medical Sciences (India)
– MNAMS” (under Regulation V of the Memorandum of
Association, Rules and Regulations). Photo Attested
by
the Proposer
to be pasted here
1. (a) Name
Surname First Name Middle Name
(b) Sex
(c) Date of Birth
(d) Nationality
2. Present Institutional/Hospital Affiliation
3. Mailing address:-
(a) Office
(b) Residence
(c) Mobile No. with S.T.D. Code Res. Office
(d) PAN No. Adhar Card No.
4. Name of State to which the candidate belongs _
5. Registration:
(i) M.C.I. Year Number
OR
(ii) State Medical Council Year Number
(Please upload an attested self-attested copy of the registration certificate)
6. Particulars of passing the DNB Examination conducted by the National Board of Examinations:
(a) Year of Passing the Examination
(b) Roll No.
(c) Subject
(Please upload an attested/self-attested copy of the degree of Diplomate National Board (DNB)
7. Professional Examination passed
Name of Examination Year University/College
(a) MBBS Final
(b) Postgraduate
Examination
(i)
(ii)
(Please upload all attested/self-attested copies of certificates)
Date
(Candidate’s signature)
List of enclosures uploaded:
Instructions:
1. Payment of Rs.10,000/- (Rs. Ten Thousand Only) ( Rs.8,000/- is towards Life Subscription
corpusRs. 2000/-as admission charges), through a Bank Demand Draft in favour of “The
Secretary, National Academy of Medical Sciences (India)”, payable at New Delhi may be
enclosed. The amount is Life Subscription.
OR
Online payment through NEFT as per details at NAMS Website: w w w . n a m s -
india.in
2. A Candidate who has already applied for Membership (MNAMS) or admitted as Member
after passing DNB examination in a speciality, if subsequently passes DNB in another or
different specialty, can apply for the Membership (MNAMS) in the subsequently obtained
speciality also (i.e. one can have two multiple Membership (MNAMS) Certificates if one
desire so, depending on the passed DNB Examination, of the NBE – MS.
