IBOMS EXAMINATION - 2011 APPLICATION FORM

Name Prof./Dr./Mr. Mrs./Ms.* Age and Sex: Address: .. State: .. City: Telephone: . Mobile:

E Mail ID: ... AOMSI membership number: Dental Council Registration Number: Present Qualification: . Date and Year of Qualification: . Institution: .......................................................... Present Position: . Institutional Attachment if any Accumulated points (to be calculated based on provided criteria): . Calculation of points (for eligibility of IBOMS examination): Documents to be attached (Photostat copies only): MDS or equivalent examination certificate Copies of experience certificate from relevant authority Documents of proof for point tally (conference certificates, publication citation etc) One photograph Demand Draft for Rs 1000 drawn in favour of IBOMS payable at Thrissur Note: The application should be sent along with a Demand Draft for Rs. 1000/ (One thousand only) in favour of IBOMS payable at Thrissur, towards the examination fee. Once the candidates pass the examination they have to pay Rs. 3000/- (Three thousand only) towards the entrance fee for the fellowship. The applications with the necessary documents should be sent to the following address: Dr.Krishnamurthy B, Dept. of Maxillofacial Surgery, Bhagwan Mahaveer Jain Hospital, Millers Road, Vasanth Nagar, Bangalore 560 052. Last date to receive the application will be 15th Oct 2011.

Dr. Suresh Menon Chairman IBOMS

Dr. Krishnamurthy Bonanthaya Secretary IBOMS