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Mahatma Gandhi University of Medical
Sciences & Technology, Jaipur
RIICO Institutional Area, Sitapura, Tonk Road, Jaipur - 302 022
Phone : +91-0141-2770798, 2771777, 2771001-3
APPLICATION FORM
MD/MS COURSES - 2015-2016
Application Form No.
[To be filled in by the applicant himself in capital letters]
Note : Please Read all the Instructions Given in the Prospectus Carefully before filling the Application Form
Applying for :
State Govt. Seats
Management Seats
(Tick üthe block)
Category: The Category should be the same as filled by the candidate in CET, 2015
(Tick üthe block)
OBC
ST
SC
SBC
Nationality :
Indian
(Tick üthe block)
01.
PIO
NRI/NRIWard
NRI Seats
General
Foreign National
Name of Candidate : (as given in Class X Certificate / MBBS Degree Certificate)
First Name :
Surname :
Photograph of the
Candidate
Father's Name :
Father’s Occupation :
Annual Income :
Signature of Candidate
Mother's Name :
Mother’s Occupation:
Annual Income :
02.
(a)
Date of Birth
03.
Gender
Male
(b) Age
Female
:: 2 ::
04.
Address for Correspondence :
PIN Code
05.
Permanent Address :
PIN Code
06.
STD Code
07.
Degree
Registration
Telephone Number
MCI
RMC
Mobile Number
Any Other State MC
Email Address
No.
Name of the State MC
08.
Whether pursuing PG Degree/Diploma Anywhere Yes
09.
Internship : Commencement (DD/MM/YY)
From
10.
No
Completion (DD/MM/YY)
To
MBBS Marks
Year of Passing
No. of Attempts Marks Obtained
Out of
% of Marks
First MBBS
Second MBBS
Third MBBS
(Part - I)
Third MBBS
(Part - II)
Aggregate
10.1 Total Marks obtained in Pre PG-CET
/
11.
Application Fee DD No.
12.
Bank - Name _________________________________________________ Branch ____________________________
13.
Choice of the PG Medical Degree Subjects
1)
_____________________________ 2)
Cash Receipt No.
_______________________ 3)______________________________
:: 3 ::
List of Enclosures with Form :
1.
Cash receipt or Bank Draft in favour of Mahatma Gandhi University of Medical Sciences & Technology, Jaipur,
Payable at Jaipur amounting to Rs. 8000.00 or USD 150.00 (in case of downloaded application forms).
2.
Self attested photocopy of class 10th certificate
3.
Self attested photocopy of (10+2) Board marks sheet
4.
Self attested photocopy of the College Leaving Certificate (Transfer Certificate) from the Principal of the Medical College
last attended
5.
Migration Certificate from the concerning university
6.
Self attested photocopy of the mark sheet of the 1st Professional Examination of the MBBS Course
7.
Self attested photocopy of the mark sheet of the 2nd Professional Examination of the MBBS Course
8.
Self attested photocopy of the mark sheet of the 3rd Professional Examination (Part I) of the MBBS Course
9.
Self attested photocopy of the mark sheet of the 3rd Professional Examination (Part II) of the MBBS Course
10.
Self attested photocopies of I, II, III MBBS (Part I & II) Attempt Certificate
11.
Internship Completion Certificate
12.
Self attested photocopy of the MBBS Degree Certificate awarded by the University
13.
Self attested copy of permanent registration certificate from RMC or State Medical Council or Medical Council of India
14.
6 Passport Size photographs
15.
Nationality and Domicile Certificate
16.
Undertakings/declaration from Candidates as per prescribed formats on non-judicial stamp papers of Rs.10/- duly attested
by Notary Public
17.
Undertakings/declarations from Parent/Guardian as per prescribed formats on non-judicial stamp papers of Rs.10/- duly
attested by Notary Public
18.
P.G. Bond/Undertaking as per prescribed format on Non Judicial stamp paper of Rs.100/-
19.
Marks obtained in Pre-PG examinations (CET organized by Central / State / or University as applicable)
20.
Cast certificate (SC/ST/OBC/SBC) for reservation category to be attached if category is other than General category. (OBC
Non Creamy Layer certificate shall be valid only if its issue-date is within one year prior to the last date of submission of the
admission application form)
Migration Certificate and Bank Guarantee will be taken after selection only
Please Tick (ü) the documents you have annexed.
I declare that all the information furnished by me in the application form is true to the best of
my knowledge. If any information found false, my application may be rejected. I will submit
my original Marks-sheets, Caste Certificate, T.C., Migration Certificate, Character
Certificate and other needed Certificate/Declarations before my admission.
Date :________________
Place :________________
Note -
(Signature of the Candidate)
Full Name : ____________________________________
Duly filled in application form must be brought in person or submitted through post in the office of the Registrar,
Mahatma Gandhi University of Medical Sciences & Technology, Sitapura, Tonk Road, Jaipur - 302 022 before the last
date as mentioned in the Notification. Incomplete application forms and the forms received after the last date due to any
reason including postal delay shall not be accepted.
Downloaded application forms shall not be accepted without cost of the application form.
For future correspondence please quote your Application Form number.
CHARACTER CERTIFICATE
From the Institution attended last
It is to certify that_____________________________________________________
S/o / D/o ________________________________________________________ who has studied in
this Institution from _______________________ to ________________________ bears a good
moral character. His/her behaviour was good with teachers and students. He/she has neither
displayed persistent violent of or aggressive behaviour nor any desire to harm others.
Name of Institution last attended : __________________________________
Signature of
Head of the Institution
with Seal
Date :___________
Declaration-1
Format for the Declaration to be filled and signed by the
Candidate on a Non-Judicial Stamp paper of Rs. 10/- duly
attested by the Notary Public
Declaration by Candidate
1.
2.
3.
4.
5.
I hereby solemnly and sincerely affirm that the statements made and information given by me in the
application form are true and correct.
I agree to abide by the Rules, Regulations and Procedures as contained in the information Brochure/
Prospectus.
At present, I have not taken admission in any Medical Post Graduate (MD/ MS) course during the previous (3)
year(s). I further declare that, if it is proved that I have secured admission for any of the Medical PG Course
earlier/discontinued after taking admission, my current year's admission shall be cancelled.
I agree to submit all the required original certificates at the time of my selection during admission process as
per the rules, failing which my claim for selection shall not be granted.
I have not concealed any material, information, however, if any information submitted herein is fraudulent,
incorrect or untrue, I understand that I am liable to criminal prosecution and I also agree to forgo my seat in
Mahatma Gandhi Medical College & Hospital, Sitapura, Jaipur. I understand that my selection and admission
to the course is also liable to be cancelled.
Date :________________
Place :________________
(Signature of the Candidate)
Candidate’s Name ______________________________
Declaration-2
Format of the Declaration to be filled and signed by the
Parent/Guardian of the Applicant on a Non-Judicial Stamp
paper of Rs. 10/- duly attested by the Notary Public
Declaration by Parent/Guardian
I _________________________________________ (Name) the parent/ guardian of the applicant, Mr. / Mrs.
________________________________________ (Name) hereby declare that I am aware of the financial obligations
of admissions of my ward to the MD/ MS Course in Mahatma Gandhi Medical College & Hospital, Sitapura, Jaipur. I
agree to pay the tuition and other fees payable to the institution as fixed from time to time as per the rules. I also affirm
and endorse the declaration made above by my ward.
Date :________________
/
Place :________________
(Signature of Parent /Guardian)
Father / Guardian's Name : ________________________
Undertaking-3
UNDERTAKING BY THE CANDIDATE / STUDENT
Format for the Affidavit to be filled and signed by the Candidates on a Non Judicial
Stamp Paper of Rs. 10/- only duly attested by the Notary Public.
STUDENT'S AFFIDAVIT
I, ________________________________________son /daughter of Shri __________________________
aged ________ resident of _______________________________ hereby state that :
1.
I have taken admission in MD/MS course in Mahatma Gandhi Medical College and Hospital, Jaipur
2.
I have carefully gone through the explanation and punishments related to ragging defined in Petition No.
646/ 98 (Vishva Jagriti v/s Central Government episode) of Supreme Court, New Delhi and I have also
made my parents aware of it.
3.
I know that the Supreme Court has banned ragging in educational institutions.
4.
I will not participate in any ragging activity during the tenure of my MD/MS course.
5.
In case I am found involved in any ragging activity, I shall be liable to punishment as per the relevant
Regulations of the Council and the Act of the Central / State Government.
Date : ____________
Place : ___________
DEPONENT
VERIFICATION
I ___________________________________ son/ daughter of Shri _______________________ aged
__________ resident of ______________________ hereby declare that the facts mentioned above from point
number 1 to 5 are true and correct to the best of my understanding, knowledge and belief. So help me God.
DEPONENT
Date : _______________
Address: ______________________________
______________________________
______________________________
(Verification by the Notary Public)
Undertaking-4
UNDERTAKING BY PARENT / GUARDIAN
Format of the Affidavit to be filled and signed by the Guardian/ Parents on Non-Judicial
Stamp paper of Rs. 10/- only duly attested by the Notary Public.
PARENT'S/GUARDIAN'S AFFIDAVIT
I, _______________________________________________ son of Shri ______________________________
aged ________ resident of _______________________________ hereby state that :
1.
My son/daughter _________________ has taken admission in MD/MS course in Mahatma Gandhi
Medical College and Hospital, Jaipur.
2.
I am aware of the explanation and punishment related to ragging defined in Petition No. 646/98 (Vishva
Jagriti v/s Central Government episode) of Supreme Court, New Delhi.
3.
My son/daughter shall not participate in any ragging during his/her MD/MS course.
4.
In case my son/daughter participates or is found involved in any ragging activity he/she shall be liable to
punishment as per the relevant Regulations of the Council, and the Act of Central / State Government.
Date : ____________
Place : ___________
DEPONENT
VERIFICATION
I ________________________________________ son of Shri ____________________________________
aged __________ resident of ______________________ hereby declare that the facts mentioned above from
point number 1 to 4 are true and correct to the best of my understanding, knowledge and belief. So help me God.
Date : ___________
DEPONENT
Address: ______________________________
______________________________
______________________________
(Verification by the Notary Public)
Declaration-5
Format for the affidavit to be filled and signed by the Parent / Guardian
AFFIDAVIT (NRI Category)
I .......................................................................... S/o ..........................................................................
Resident of .......................................................................................................................do hereby
solemnly affirm and declare as under :1.
That I am bonafide "Indian Foreign National", holder of passport No. ..........................
.......................................................................................................................................
2.
That I am residing abroad in ........................................................ (name of the country)
since ............................. and presently working in ........................................................
3.
That I am holder of requisite bank A/c in India / Account in Foreign Exchange
in........................................................ I do hereby undertake that all requested fees for
my Daughter / Son / Dependent ................................. will be paid in the requisite
exchange.
4.
That I am a Non-Resident Indian from ............................................................................
5.
That I hereby again undertake that all the expenditure for my Son / Daughter /
Dependent will be borne by me if he/she gets admission against the N.R.I. Quota.
DEPONENT
VERIFICATION
Verified at ............................................ on ........................................... that the contents
of the above affidavit are true and correct to the best of my knowledge and belief.
Place : ________________
Date : _____________
DEPONENT
Mahatma Gandhi University of Medical
Sciences & Technology, Jaipur
RIICO Institutional Area, Sitapura, Tonk Road, Jaipur - 302 022
Phone : +91-0141-2770798, 2771777, 2771001-3
MD/MS Course
Session 2015-2016
Application Form No.
INTERVIEW CALL LETTER
Post Graduate
2015 - 2016
Convener (Admissions)
Mahatma Gandhi University of Medical
Sciences & Technology, Jaipur
RIICO Institutional Area, Sitapura, Tonk Road, Jaipur - 302 022
Phone : +91-0141-2770798, 2771777, 2771001-3
MD/MS Course
Session 2015-2016
Application Form No.
ACKNOWLEDGEMENT RECEIPT
Registrar
Mahatma Gandhi University of Medical Sciences & Technology, Jaipur
ADMIT CARD – Student Copy
Entrance exam for admission to MD/MS courses January, 2015
Roll No.
Name of Centre – Mahatma Gandhi Medical College, Jaipur – Exam Hall
Date of Exam :
Affix Photo
Exam Time :
Name of Candidate
Father’s Name
Signature of Student
All details in the Admit Card are correct
Signature of Student
Sign. & Seal of the Centre Superintendent
Controller of Examinations
Mahatma Gandhi University of Medical Sciences & Technology, Jaipur
ADMIT CARD – Centre Copy
Entrance exam for admission to MD/MS courses January, 2015
Roll No.
Name of Centre – Mahatma Gandhi Medical College, Jaipur – Exam Hall
Date of Exam :
Affix Photo
Exam Time :
Name of Candidate
Father’s Name
Signature of Student
All details in the Admit Card are correct
Signature of Student
Sign. & Seal of the Centre Superintendent
Controller of Examinations