THE WEST BENGAL UNIVERSITY OF HEALTH SCIENCES
DD – 36, Sector – 1, Salt Lake, Kolkata 700 064 West Bengal, India.
 
     
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Online Application for Competency Based Evaluation Test  
1. *Name of the Doctor :   
2. *Father/Husband’s 's Name :   
3. * Gender :  
4. *Date of Birth(DD/MM/YYYY) :    
5. *Address for Communication :  
        5.1. *District :  
        5.2. *State :  
        5.3.*PIN :  
6. *Mobile No.:     
 
7. *Email Id :    
8. *Registration with the council (WBMC/MCI) :  
   
9. *Address of Clinic/ Hospital/ Medical College :  
10.  Registration Number under PCPNDT Act 1994 :
11. Date of issue of registration Number of the Clinic :
12. *Period of attachment :    
13. When the license was renewed :
 
14. *Upload Images :
Photo size should be between 5KB and 100KB.
15. *Upload Signature :
Signature size should be between 5KB and 100KB.
*Name of the Bank: *Name of the Branch: *DD Number *Amount: *Date(DD/MM/YYYY):