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Basic Information

Title: First Name: Middle Name: Last Name:
Gender: Marital Status:
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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

Medical Registration

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

Employment Information

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Course & Payment Details

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Visitor Survey

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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.