• 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:
Upload Passport Size Photo
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: Residence Telephone: Email ID:
Clinic Telephone: Alternate Telephone: 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 / OrganisationName Year
1.
2.
3.
4.
5.

Medical Registration

Medical Registration Type: Medical Registration No.:
Are you member of IMA: IMA Registration No.: IMA Local Chapter name:

Employment Information

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

Course & Payment Details

Course: Payment Mode: Payment Amount:
I will pay the course fee by:
ChequeDemand DraftOnline NEFT Transfer

Visitor Survey

How did you discover us:
Are you willing to travel for clinical postings?
What other courses would you like us to offer?
Refer us to your friends

Terms & Conditions:


1. I hereby declare that I am an MBBS/MBChB/MD Doctor registered with Medical Council in my Country and licensed to practice Modern Medicine.

2. I have read and understood all the Terms and Conditions on this website and unconditionally accept them as binding on me. I will send my MBBS and Medical registration Certificates and pay the required fee for admission.

3. I understand that Fee once paid will not be refunded under any circumstances. (Please click here to read the "No-refund" policy)

4. I understand that switching from one course to another course after enrollment is not allowed. (Please click here to read the FAQs)

5. I agree that I have to finish my course within the course duration (6 months for Certificate courses, 1 year for Fellowship courses and 2 years for Diploma in Family medicine course). I agree that if I don't finish my course within the above duration, I have to retake the admission and pay the fee once again.(Please click here to read the FAQs)

6. I further declare under Penalty of Perjury that the above information provided by me is true and correct in all aspects. I hereby indemnify IMA eVarsity and its partners against damages of any nature caused due to erroneous or falsified data submitted by me.

I have read the terms and conditions, No refund policy and Disclaimer on this website. I fully agree to abide by the Disclaimer and Terms & Conditions listed in the prospectus, and on the IMAeVarsity web site.