APPLICATION FOR ADMISSION TO M.B.B.S./B.D.S./PG Course Year:

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1 YENEPOYA MEDICAL & DENTAL COLLEGE Nithyananda Nagar P.O., Deralakatte, Mangalore , INDIA [Founded by Islamic Academy of Education (Regd.) Mangalore] Affiliated to Rajiv Gandhi University of Health Sciences, Bangalore and approved by Govt. of Karnataka, Medical Council of India & Dental Council of India. APPLICATION FOR ADMISSION TO M.B.B.S./B.D.S./PG Course Year: (To be filled in by the Applicant in BLOCK letters) [Incomplete applications will not be considered] Registration Number: For Office use Application fee Rs. paid by cash /D.D. No. Passport Size Photograph Here dated on Regn. Fee Rs. paid by Cash / D.D. No Dated on Last date for receipt of completed Application I. GENERAL INFORMATION: 1. Name of the Applicant : (As appearing in the marks card of qualifying examination) 2. Sex : Male / Female 3. Date of Birth : Day Month Year 4. Blood Group : 1

2 5. Place of Birth Place : State : Country : 6. Religion : 7. Caste (SC/ST/BC/BT/GEN) : 8. Marital Status : Married / Single 9. Mother Tongue : 10. Languages Known To Speak : To Read : To Write : 11. Nationality (Country of Origin) : 12. Citizen : 13. If Indian Citizen, whether NRI : 14. If not NRI, State of Domicile : 15. Father s Name : 16. Guardian s Name : (Only if Father is deceased) Relationship : 17. Profession of Father/Guardian : 18. Annual income of Father/Guardian: 2

3 19. Permanent Address of Father /Guardian Pin : : Phone : Fax : 20. Postal Address (if different from above) : Pin : Phone : Fax : 21. Name and Address of Local Guardian if any : Pin : Phone : Fax : 3

4 22. References: (At least two persons holding responsible positions and not related to the Applicant) i) Name : Address : Pin : Phone : Fax : ii) Name Address Pin Phone Fax : : : : : : 4

5 II. A. DETAIL OF ACADEMIC QUALIFICATIONS (M.B.B.S. & B.D.S. Applicants only) Year of Passing Institution Studied Reg. No. University Board 01. Standard X SSLC or Equivalent 02. Qualifying examination PUC or Equivalent (10+2) 03. Any other Higher Education Subjects Maximum Marks Marks Obtained Percentage No of Attempts Physics Chemistry Biology Total English (Please attach attested copies of statement of marks in support of the above details) Note: In case the results of the qualifying examination is not declared, the attested copy of the marks sheets should be submitted at the earliest. Name and Address of the Institution last Studied/ Studying 5

6 II. B. DETAIL OF ACADEMIC QUALIFICATIONS ( M.D.S. Applicants only) Percentage Distinction if any No. of Attempts I B.D.S II B.D.S III B.D.S IV B.D.S PART I Details of Internship PART II FROM COLLEGE TO (Please attach attested copies of statement of marks in support of the above details) Note: In case the results of the qualifying examination is not declared, the attested copy of the marks sheets should be submitted at the earliest. Name and Address of the Institution last Studied/ Studying PREFERENCE OF SPECIALITY:

7 II.C. DETAIL OF ACADEMIC QUALIFICATIONS MEDICAL PG COURSES (MD/MS) MBBS Phase I MBBS Phase II MBBS Phase III Part I Part II Percentage Distinction if any No. of Attempts Details of Internship FROM TO COLLEGE (Please attach attested copies of statement of marks in support of the above details) Note: In case the result of the qualifying examination is not declared, the attested copy of the marks sheets should be submitted at the earliest. Name and Address of the Institution Last studied/studying Whether the Institution is recognized by MCI Yes/No PREFERENCE OF SPECIALITY

8 III. DECLARATION BY THE APPLICANT I wish to apply for admission to the Yenepoya Medical College / Yenepoya Dental College, Mangalore, and I declare that to the best of my knowledge and belief, the above particulars are true. I agree that the admission is at the sole discretion of the management. I have gone through instructions for admission carefully, and I undertake to abide by all the conditions. I further agree, if admitted, to conform to the rules and regulations at present in force or that may thereafter be made for the administration of the College and Hostel. I undertake, so long as I am a Student of the college, I will not do anything unworthy of a student or anything that will interfere with its orderly working and discipline. I am aware that the management has the full authority to expel me for disinterest in studies, misbehaviour and continuous failures. Place : Date : Applicant s Signature DECLARATION BY THE PARENT / GUARDIAN I hereby declare that I know the financial obligation and I can afford and undertake to pay the tuition and other fees payable to the Institution under the rules of the college. Place : Date : Signature of Father/ Guardian ADMISSION STATUS Provisionally admitted / kept pending / reserved for the year Fee Paid vide receipt No. Remarks, if any: Accountant Manager 8

9 Director [A &A] Principal. YENEPOYA MEDICAL & DENTAL COLLEGE Nityananda Nagar P.O., Deralakatte, Mangalore , INDIA (Founded by Islamic Academy of Education) YEAR.. COMMONENTRANCE TEST FOR ADMISSION TO MEDICAL/DENTAL/PG, MEDICAL & DENTAL COURSES. HALL TICKET REG. No. Please affix your passport size photograph here CENTRE: EXAMINATION HALL YENEPOYA MEDICAL & DENTAL COLLEGE DERALAKATTE, MANGALORE Name: Mr./Mrs.... Son/Daughter of Mr./Mrs Signature of the Candidate CHIEF SUPERINTENDENT. INSTRUCTIONS TO THE CANDIDATES 1. The Candidates shall be present at the examination center 40 minutes before the commencement of the examination. 2. Possession of valid admission ticket is mandatory, loss of admission ticket for any reason shall be brought to the notice of the chief superintendent at least one hour before the commencement of the examination 9

10 3. Copying and malpractice of any kind are strictly prohibited. 4. Possession of any kind of electronic gadgets (Cell phone, calculator etc)is prohibited in the examination hall. 10