ADMISSION TO MBBS/BDS COURSE SESSION COMMON APPLICATION FORM (GENERAL CATEGORY) SELECTION COMMITTEE DIRECTORATE OF MEDICAL EDUCATION

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1 ADMISSION TO MBBS/BDS COURSE SESSION COMMON APPLICATION FORM (GENERAL CATEGORY) SELECTION COMMITTEE DIRECTORATE OF MEDICAL EDUCATION RANDOM NUMBER APPLICATION REGISTRATION NUMBER (To be assigned by Selection Committee) EXAMINATION REGISTER NUMBER, YEAR AND MONTH : (To be alloted by Selection Committee) REGISTER NUMBER YEAR MONTH 2. NAME IN BLOCK LETTERS (INITIAL AT THE END) 3 ADDRESS FOR COMMUNICATION PIN Contact PHONE NO. (with STD Code) : MOBILE NO. : 4. NAME OF PARENT / GUARDIAN 7. NATIVITY 7A. DETAILS OF NATIVITY (ENCIRCLE A CODE) (ENCIRCLE A CODE WHICHEVER APPLICABLE) TN OTHERS 1 2 Nativity Tamil Nadu and Studied VIII Std to +2 in Tamil Nadu Nativity Tamil Nadu but Studied VIII Std to +2 in Other State Nativity Other State but Studied VIII Std to +2 in Tamil Nadu SPACE FOR PHOTOGRAPH (TO BE ATTESTED BY GRADE A/B OFFICERS OF CENTRAL/ STATE GOVERNMENTS) 5. SEX MALE FEMALE (ENCIRCLE 1 2 A CODE) 6. NATIONALITY INDIAN OTHERS (ENCIRCLE 1 2 A CODE) Nativity Other State and Studied VIII Std to +2 in Other State Nativity Tamil Nadu but Studied Partly in Tamil Nadu SCHOOL(S) OF STUDY (EVIDENCE TO BE PRODUCED FROM THE SCHOOLS STUDIED) STANDARD PINCODE NAME OF THE NAME AND ADDRESS OF SCHOOL STUDIED NUMBER STATE OF SCHOOL VIII STD IX STD X STD XI & XII STD/ EQUIVALENT 1

2 9. DATE OF BIRTH 10. COMMUNITY (ENCIRCLE A CODE) DATE MONTH YEAR O.C B.C. BCC BCM MBC/DC S.C. S.T CASTE CODE 12. NAME OF THE CASTE... REFER LIST OF COMMUNITIES (FOR OC USE CODE 500) 13. QUALIFYING EXAMINATION 14. MEDIUM OF INSTRUCTION (ENCIRCLE A CODE) (ENCIRCLE A CODE) H.S.E. SSCE/CBSE I.S.C.E. OTHERS ENGLISH TAMIL OTHERS PARTICULARS OF PASSING THE 16. MARKS OBTAINED IN SELECT SCIENCE QUALIFYING EXAMINATION (+2) SUBJECTS IN THE QUALIFYING EXAMINATION IN THE FIRST ATTEMPT ONLY FIRST ATTEMPT REG. NO. SUBJECT MAXIMUM MARKS MARKS OBTAINED MONTH & YEAR PHYSICS CHEMISTRY BIOLOGY BOTANY ZOOLOGY SUBJECT MAXIMUM MARKS 17. MARKS OBTAINED IN THE FOURTH MARKS OBTAINED OPTIONAL SUBJECT 18. IF YOU HAVE BEEN / OR PRESENTLY A STUDENT OF A PROFESSIONAL COLLEGE IN TAMIL NADU, FURNISH PARTICULARS. IF NOT, WRITE _ N.A. (NOT APPLICABLE) NAME OF COURSE MONTH, YEAR FROM TO NAME AND PLACE OF COLLEGE 2

3 19(a) IF CLAIMING FOR SPECIAL CATEGORIES, HAVE YOU APPLIED IN THE FORM PRESCRIBED FOR SPECIAL CATEGORY (PUT 4 ) (b) IF YES, SPECIFY THE SPECIAL CATEGORY APPLICATION FORM NO. (Maximum of three special categories only permissible) YES NO S.l. Form No. Spl. Cat. Code No. I ii iii 20. RELIGION : 21. MOTHER TONGUE : 22. NATIVE DISTRICT CODE (AS GIVEN IN PROSPECTUS) 23. CIVIC STATUS OF YOUR NATIVE PLACE AND SCHOOL PLACE (ENCIRCLE A CODE) CORPORATION MUNICIPALITY TOWNSHIP TOWN VILLAGE OTHERS PANCHAYAT PANCHAYAT NATIVE PLACE SCHOOL PLACE OCCUPATION OF PARENT / GUARDIAN (ENCIRCLE A CODE) STATE CENTRAL PROFESSIONAL INDUSTRY BUSINESS AGRICULTURE PRIVATE SMALL OTHERS GOVERNMENT GOVERNMENT ORGANI- TRADE SATION AVERAGE MONTHLY INCOME OF PARENT / GUARDIAN (ENCIRCLE A CODE) BELOW Rs.3000 Rs Rs Rs Rs Rs ABOVE Rs EDUCATIONAL STATUS OF THE FAMILY (ENCIRCLE A CODE) IF ADMITTED WILL YOU BE THE FIRST GRADUATE IN THE FAMILY (REFER INSTRUCTIONS) YES NO 1 2 Signature of the Parent / Guardian Date : Signature of the Candidate Date: 3

4 27. DECLARATION BY THE APPLICANT I... (Name in full and in Block Letters) SON/ DAUGHTER WARD of.. an applicant for MBBS / BDS course session hereby solemnly declare that I have not claimed any dual Nativity in this regard and I belong to... (Community) and the Sub Caste is.... I also declare that the information and the statements given in the application, OMR Sheets and enclosures are true, correct and complete. I further declare that if it is found otherwise, I will be liable to forfeit the seat and / or be removed from the rolls of the institution at whatever stage of study, I may be, besides making me liable for criminal prosecution. PLACE : DATE : SIGNATURE OF THE APPLICANT 28. DECLARATION BY THE PARENT / GUARDIAN I... (Name in full and in Block Letters) Father / Mother / Guardian of.. hereby solemnly declare that the Community and the Nativity claimed by my Son / Daughter / ward Thiru / Selvi /... are correct and he / she has not produced any false certificate in this regard and not claiming nativity in any other state. I also declare that the information and the statements given in the application, OMR Sheets and the enclosures are true, correct and complete. I further declare that if it is found otherwise, my ward will be liable to forfeit the seat and / or be removed from the rolls of the institution at whatever stage of study, I and my ward may be, besides making me liable for criminal prosecution. PLACE : DATE : SIGNATURE OF THE PARENT / GUARDIAN Note : The Guardian can execute the above declaration only if both parents are not alive. 4

5 A.R. No. : ACKNOWLEDGEMENT CARD The receipt of your application for admission to M.B.B.S. / B.D.S. DEGREE COURSE SESSION IS ACKNOWLEDGED Secretary Selection Committee Chennai * Write your mailing address and affix postal stamps to the value of Rs on the reverse in the space provided. Affix Rs Postage Stamp To PINCODE

6 INFORMATION OF MEDICAL / DENTAL COLLEGES FOR SESSION GOVERNMENT / SELF FINANCING MEDICAL/DENTAL COLLEGES MBBS/BDS COURSE MBBS COURSE Phone Nos. Nearest Hostel Facilities No. College Address & Railway Station/ Availability for Fax No. Bus stop Boys Girls 1. Dean, Ph: Central Rly. Station ½ Km Madras Medical College, Fax : Park Town Bus Stand ½ Km Yes Yes Periyar EVR Road Park Town, Chennai Dean, Std Code 044 Washermenpet Rly Station, Yes Yes Stanley Medical College, Ph: with in a km M.C. Road, Fax : Bharathi Arts College for Chennai - 1 Women stop, Walkable Distance 3. Dean, (0452) Madurai Railway Station Yes Yes Madurai Medical College, Ph. : to 42 (Junction) 3 Kms Panagal Road, Madurai Fax : Anna Bus Stand ½ km 4. Dean, (04362) Thanjavur Railway Station 5 Kms Yes Yes Thanjavur Medical College, Ph: New Bus Stand 3 Kms Thanjavur, Pin Fax: (04362) Old Bus Stand - 5 Kms 5. Dean Std KMC Bus Stop (Walkable Yes Yes Kilpauk Medical College Ph: distance) Poonamallee High Road, Park, 3 Kms Kilpauk, Chennai Central, Egmore - 3 Kms Fax : Chetpet - 1km. 6 Dean Ph. & Fax. Chengalpattu Jn. 3 Kms Yes Yes Chengalpattu Medical College, Chengalpattu Bus Stop 3 Kms. Chengalpattu Kanchipuram Dist 7. Dean Ph. : Tirunelvely Railway Station 6 Kms Yes Yes Tirunelveli Medical College, , Nearst Bust Stop Tirunelveli, Pin Fax : High Ground ½ Km, New Bus stand 8. Dean Ph. : (0422) Coimbatore Junction 10 Kms Yes Yes Coimbatore Medical College Medical College Bus Stop Avinashi Road, (College Opposite) Peelamedu, Fax : 0422 Coimbatore Dean (0427) Salem Junction 7 Kms Yes Yes Govt. Mohan Kumara Fax : (0427) Nearest Bus Stop Mangalam Medical College Medical College Bus stop Salem, Pin

7 Phone Nos. Nearest Hostel Facilities No. College Address & Railway Station/ Availability for Fax No. Bus stop Boys Girls 10. Dean, Ph. : (0431) Tiruchy Junction 1 Km Yes Yes K.A.P. Viswanatham Govt Bus Stop Medical College, Fax : Medical College entrance Pariyamilaguparai Bus Stop Less than ¼ Km Tiruchirapalli Dean, Ph:(0461) Thoothukudi, Rly, Station 6 Kms Yes Yes Thoothukudi Govt. Medical Fax : Old Bus Stand - 4 Kms. College, 3rd Mile, Kamaraj Nager Thoothukudi Dean, Ph:04652 Nearest Railway Station Yes Yes Kanyakumari Government , Nagerkiol - 6 Kms. Medical College Vadasari Bus Stand - 6 Kms Asari Pallam Fax : & Nagercoil Bus Stand - 6 Kms K.K. District Dean, (0416) Katpadi Railway Station 15 Kms Yes Yes Govt. Vellore Medical College, Vellore Bus Stop - 10 Kms Vellore Fax : Dean Ph Theni Yes Yes Govt. Theni Medical College, , Medical College Theni , Bus Stop ½ Km Fax : Dean Ph. : Erode - Rly. Station 22 Kms. Yes Yes IRT Perundurai Medical College, to Bus Stop. Perundurai - 2 Kms. Perundurai, Sanitorium Fax : Erode District, 16. Principal Ph. : 0422 Coimbatore Central Yes Yes P.S.G. Institute of Medical Lines Railway Station - 7 Kms Sciences & Research Lines Peelameeju Bus Stop Mts. Post Box No Fax : Avanashi Road, Peelamedu, Coimbatore The Director Ph. : Kuzhithurai Railway Yes Yes Sree Mookambika Institute of Station - 12 Km Medical Sciences Bus Stop Kulasekharam Velayuthan Pillai Memorial Fax: feet. Hospital Complex, Padanilam, Kulasekharam K.K. District. 18. Dean Ph. : 044 Tambaram Railway Yes Yes Chettinad Hospital & , Station 25 Kms Research Institute , Bus Stop -Kelambakkam 2 Kms I.T. High Way, Fax : Kelambakkam, Padur, Kanchipuram Dist

8 BDS COURSE Phone Nos. Nearest Hostel Facilities No. College Address & Railway Station/ Availability for Fax No. Bus stop Boys Girls 19. Principal, Ph. : 044 Near Chennai Fort Rly. Station Yes Yes Tamil Nadu Govt Dental Hospital Bus Stop Dental College & Hospital adjacent to the College entrance Dr. Muthusamy Road, Chennai Fax : Opp. to Fort Rly. Station 20. The Principal Ph:(044) Tambaram Railway Yes Yes Ragas Dental College & Hospital to Station - 15 Kms 2/102, East Coast Road, College Bus Stop - 20 feet Uthandi, Chennai Fax: The Principal Ph:04288 Erode Railway Station - 10 Kms Yes Yes J.K.K. Nataraja Dental , Komarapalayam - Vattamalai College & Hospital Bus Stop. Komarapalayam Fax : Namakkal Dist. 22. The Director, Ph. : Kuzhithurai Railway Yes Yes Sree Mookambika Institute of Station - 12 Km Dentall Sciences Bus Stop Kulasekharam Velayutham Pillai Memorial Fax: feet Hospital Complex, Padanilam, Kulasekharam K.K. District. 23. The Principal, Ph Nearest Railway Station Yes Yes Rajas Dental College & Hospital , Valliyoor - 20 Kms. Thirurajapuram, , Nagercoil - 25 Kms. Kavalkinaru Junction, Fax : Kavalkinaru Junction Tirunelveli Dist Walkable distance 24. The Principal Ph. : Erode Railway Station - 12 Kms Yes Yes K.S.R. Institute of Dental / , Opp College KSR Science & Research Kalvi Nagar on Thokkavadi Post, Fax : Erode - Tiruchengode Tiruchengode Namakkal Dist. 25. The Principal Ph. : 0422 Nearest Railway station Yes Yes Sri Ramakrishna Dental Coimbatore 6 Kms. College & Hospital Fax : Nearest Bus stop S.N.R. College Road, Nava India Kms. Coimbatore The Principal Ph. : 044 Melmaruvathur Railway Yes Yes Adhiparasakthi Dental Station ½ Km from College College & Hospital Bus Stop ½ Km from College Melmaruvathur, Fax: 044 Kanchipuram Dist , Principal, Ph. : 044 Nearest Railway Station Yes Yes Sri Venkateswara Dental Velachery - 9 Kms. College & Hospital Fax : Bus stop - Thalambur Mts. Opp. Old Mahabalipuram Road Thalambur Village, Kancheepuram Dist. 61

9 Phone Nos. Nearest Hostel Facilities No. College Address & Railway Station/ Availability for Fax No. Bus stop Boys Girls 28. The Principal Ph: Nearest Railway Station Yes Yes Vivekananda Dental College (4 Lines) Erode - 25 Kms for Women & 91 Nearest Bus Stop Elayampalayam Fax: Tiruchingode - 6 Kms. Tiruchengode (TK) , Namakkal Dist 29. The Principal Ph:0452 Nearest Railway Station Yes Yes Best Dental Science College , Madurai Junction - 12 Kms. Ultra Trust, No.69/1A Melur Road Fax : 0452 Bus Stop -Mattuthavani - 4 Kms. Vowalthottam (P.O.) Madurai The Principal Ph. : 044 Nearest Railway Station Yes Yes Karpaga Vinayaga Institute of Chengalpet - 15 Kms. Dentall Sciences, , Nearest Bus stop GST Road, Palayanoor Post, Fax : Padalam - 1 Km. Chinnakolambakkam, Madhuranthagam Taluk, Kancheepuram. District The Principal, Ph. 044 Nearest Railway Station Yes Yes Priyadharshini Dental , Thiruvallur - 6 Kms. College & Hospital , Nearest Bus Stop Pandur 1, VGR Gardens, VGR Nagar, Fax : Pandur , Thiruvallur TK & Dist. 32. The Principal Ph. : 044 Nearest Railway Station Yes Yes Madha Dental College& Hospital Pallavaram - 8 Kms. Madha Nagar, Fax : Nearest Bus Stop Somangalam Road, Kundrathur - 1Km. Kundrathur, Chennai The Principal Ph. : 0452 Nearest Railway station Yes Yes CSI. College of Dental Madurai Junction 2 Kms. Scicnces and Research Fax : Nearest Bus stop 129, East Veli Street, Front of College Madurai The Principal Ph. : 044 Nearest Railway Station Yes Yes Chettinad Dental College & , Vanadalur - 14 Kms. Research Institute Fax: 044 Bus Stop Kelambakkam Mtrs. I.T. High way, Kelambakkam, Kanchipuram Dist The Principal Ph. : Nearest Railway Station Yes Yes Tagore Dental College & Fax: Vanadalur - 7 Kms. Hospital Bus Stop Rathinamangalam - 1/2 Km. Rathinamangalam, Vandalore P.O., Chennai The Chairman, Ph. : The Trichy Rajas Dental Fax No. : 0431 College & Hospital Raja Nagar, Nagamangalam Tiruchirapalli

10 # MBBS / BDS Course ADMISSION SESSION PRE - DESPATCH CHECK LIST FOR THE USE OF THE APPLICANT It is the candidate s own responsibility to exercise suitable checks and ensure that his / her application is correct and complete in all respects. As a facility for a further check, a list of tasks are given below. Against each task-description, the candidate should put a tick mark (4) or write N.A. to indicate that the task has been done or is Not Applicable to him / her. 1. DATA Registration Number, year and month entered in the Application, OMR Sheets and cover for return of documents : 1.2 Application and OMR Sheets filled up : 1.3 Checked and confirmed that corresponding entries in Application Form and OMR Sheets tally and that there is no discrepancy : 2. SUPPORTIVE DOCUMENTS Attested Xerox Copies of the following enclosed 2.1. Qualifying Exam mark sheet (both sides) : 2.2 Latest permanent Community Certificate : 2.3 Latest Transfer Certificate (T.C.) : 2.4. Nativity Certificate (If Applicable) : 3. MISCELLANEOUS 3.1 Attested Passpost size photograph affixed in the Application : 3.2 Self - addressed and sufficiently stampted acknowledgementcard : # Date : Signature of the Applicant Note : This form should be detached and submitted along with filled-in-application form. 63