Form for Enrollment/Eligibility of Post Graduate/ Super specialty Course for. Admission Year

Transcription

1 1 MADHYA PRADESH MEDICAL SCIENCE UNIVERSITY, JABALPUR (M.P.) ENROLLMENT NUMBER (For University use) To The Registrar Madhya Pradesh Medical Science University, Jabalpur (M.P.) Sir, I request permission to enrol myself at the ensuing Post Graduate/ Super specialty course in the batch I furnish my details as stated below:- 1.College Name Form for Enrollment/Eligibility of Post Graduate/ Super specialty Course for Admission Year FACULTY 3. COURSE CODE 4. Left Hand Thumb Impression of the Candidate 5. Signature of the Candidate in running hand, within the box only Candidate s Name in Capital Letters (Strictly as per Class XII or Gazette Notification): FIRST NAME MIDDLE NAME SURNAME 6. Paste (do not staple) recent Photograph duly attested by the Dean/ Principal/ Head of the Institution. 7. Date of Birth Date Month Year 8. Gender Male Female 9. Category SC ST OBC UR 10. Special Reservation if any (Specify. like In-Service) 11. Admission Month Date Month Year 12. MOTHER S NAME in Capital Letters 13. FATHER S/HUSBAND NAME in Capital Letters 14. Candidate s mailing address in CAPITAL Letters only House no. Street State Building/ Locality City Pin Code 15. id of Student 16. id of Father/ Mother (if available) 17. Mobile no of student 18. Mobile no of Father/ Mother 19. NATIONALITY Indian NRI Foreigner (Specify) M.P. State 20. DOMICILE Out of M.P. State If OMPS. Specify State 21. Aadhar Card Number of Student (for Indian Nationals) 22. Details of Qualifying Examination (UG/PG) passed Name of University Name of College Name of Course Year of Admission Year of Passing 23. Details of Entrance Examination passed Exam (AI/DMAT/ Other) Roll number Total Marks and % Rank in Common list Rank in Category list Total Fee Submitted 24. Fee Submission Detail Receipt Number 25. Central/State Council Registration No. & Date

2 2 26. DECLARATION BY THE CANDIDATE I.. Son/ Daughter/ of Admitted in Course..Admission Year in the College hereby declare that above information furnished by me is correct. If any information furnished by me is found fraudulent/incorrect/untrue at a later date, I am aware that my admission is liable to be cancelled and civil/criminal action can be prosecuted against me. I am fully aware that the University shall return my application of enrolment towards non-compliance of documents within a period of 90 days from the date of admission. I have perused eligibility rules for admission and thereby declare that I am eligible to be enrolled with the University. I am also aware that late fees shall be attracted towards late submission of eligibility documents as prescribed by the University. Date : Signature of Candidate I certify that entries made by the candidate in the application form are correct and have been verified from the original documents. On perusal of documents, it is found that the candidate is eligible for the admission to the course as per prescribed norms. It is apprised to the candidate to comply-with requisite documents within a period of 90 days, falling which his/her admission shall be cancelled by the Colleges. Office Seal Signature of the Dean/Principal Of the College/Institute

3 3 Checklist of documents to be submitted by the candidate (Put whichever applicable) Sr.No. Particular of documents Original Attested 1 a. Nationality Certificate issued by District Magistrate/Additional District Magistrate/Chief Metropolitan Magistrate or b. Photocopy of Valid Passport duly attested by Dean/Principal/Director or c. Domicile certificate or d. Birth Certificate endorsed with Nationality as Indian on it. 2 Secondary School Certificate (SSC) 3 Higher Secondary School Mark Sheet/Qualifying Examination Mark Sheet/ (HSC) 4 Mark sheet of UG Examination passed 5 Mark sheet / Degree of PG Examination passed (if applicable) 6 Entrance Examination Marks Sheet 7 AIPG/GOI/Competent Authority Selection letter (if applicable) 8 Caste Certificate (If applicable) (It is mandatory to the candidate belonging to reserved category to submit Caste Certificate duly supported by Caste Validity Certificate & Non-Creamy Layer Certificate (If Applicable) Failing which proposal will not be accepted) 9 Valid Non-Creamy Layer Certificate (IF applicable) 10 College Leaving Certificate (LC/TC) 11 Copy of Gazette for change in name (IF applicable) 12 Migration Certificate issued by the respective Board/University applicable to a) Students who have passed HSC examination from outside M.P. b) After passing HSC/Qualifying examination, students who have joined Any other course for period of more than six months 13 Affidavit Gap Certificate (made by the student duly certified by Executive Magistrate/Notarised (if applicable) 14 Medical Fitness Certificate duly quoted with Registration number (as per the format prescribed in the Information Brochure by respective Competent Authority) 15 Physically Handicapped Certificate (as per the format prescribed in the information Brochure by respective Competent Authority) (if applicable) 16 Copy of Aadhar Card 17 Students admitted in NRI quota required to submit a. Equivalence Certificate issued by Association of Indian University (AIU) b. Grade marks/credit point conversion as per Indian marks issued by respective Board/University Photocopy Note :- 1. It is mandatory to submit above documents in chronological order with one set of original and one set of attested Photocopies. However, original documents specified at Sr. No. 11, 12 & 13 to be attached with set of photocopies, which will be retained by the university. 2. Status of submission of documents shall be subject to verification by MPMSU office. Place: Signature of Candidate in running hand Annexure - 1

4 4 No... ENROLLMENT/ ELIGIBILITY FEE RECIEPT (COLLEGE COPY) Batch NAME OF THE CANDIDATE:. COLLEGE NAME AND CODE:. TOTAL AMOUNT OF FEE DEPOSITED SIGNATURE OF CANDIDATE SIGNATURE AND SEAL OF COLLGE AUTHORITY ENROLLMENT/ ELIGIBILITY FEE RECIEPT (COLLEGE COPY) Batch No... NAME OF THE CANDIDATE:. COLLEGE NAME AND CODE:. TOTAL AMOUNT OF FEE DEPOSITED SIGNATURE OF CANDIDATE SIGNATURE AND SEAL OF COLLGE AUTHORITY ENROLLMENT/ ELIGIBILITY FEE RECIEPT (COLLEGE COPY) Batch No... NAME OF THE CANDIDATE:. COLLEGE NAME AND CODE:. TOTAL AMOUNT OF FEE DEPOSITED SIGNATURE OF CANDIDATE SIGNATURE AND SEAL OF COLLGE AUTHORITY

5 5 FACULTY 1. MEDICAL 2. DENTAL 3. AYURVEDA 4. UNANI 5. SIDDHA 6. HOMEOPATHY 7. NATUROPATHY & YOGA 8. NURSING 9. PARAMEDICAL CODING OF COURSES S.No. FACULTY FACULTY CODE 1. Medical M 2. Dental D 3. Ayurvedic A COURSE COURSE SPECIALIZATION COMPLETE CODE CODE COURSE CODE MBBS (UG) M0000 MD/MS (PG) M0100 Diploma (PG) M0200 M.Ch /DM M0300 Ph.D M0500 Fellowship M0600 BDS (UG) D0000 MDS D0100 Ph.D D0200 Fellowship D0300 BAMS(UG) A0000 MD (PG) A0100 Ph.D A0200 Fellowship A Unani U BUMS(UG) U0000 MD(PG) U0100 Ph.D U0200 Fellowship U Siddha S BSMS(UG) S0000 MD(PG) S0100 Ph.D S0200 Fellowship S Yoga&Naturopathy Y BNYS(UG) Y0000 MD(PG) Y0100 Ph.D Y0200 Fellowship Y Homeopathy H 8. Nursing N BHMS (UG) H0000 MD(PG) H0100 Ph.D H0200 Fellowship H0300 BSC (UG) N0000 MSC (PG) N0100 Post Basic Nursing (UG) N0200 Ph.D N0300 Fellowship N0400 Bachelor of Physiotherapy (BPT) P0000 Master of Physiotherapy (MPT) P0000 Bachelor in Medical Lab. (BMLT) P0300

6 6 9. Paramedical P Post Graduate Degree in Medical P0300 Lab. Diploma in Medical Lab P0400 Bachelor in Human Nutrition P0500 Diploma in Human Nutrition P0600 Bachelor Occupational Therapy P0700 Bachelor of Speech Therapy P0800 Bachelor of X-Ray (Radiographer) P0900 Diploma in X-Ray (Radiographer) P1000 Diploma in Homoeopathic P1100 Compounder Diploma in Unani Compounder P1200 Diploma in Ayurvedic Compounder P1300 Diploma in Pharma (Ayurved) P1400 Diploma in Optometric & P1500 Refraction Diploma in Opthalmic Assistant P1600 Diploma in Microbiology P1700 Diploma in Blood Transfusion P1800 Diploma in Biochemistry P1900 Diploma in Dialysis P2000 Diploma in Perfusionist Cardiac P2100 Surgery Diploma in Anasthesia P2200 Diploma in C.T.M.R.I P2300 Diploma in Cath. Lab P2400 Diploma in Gamma Camera P2500 Diploma in Dental Hygiene P2600 Diploma in Dental Mechanic P2700