MGM INSTITUTE OF HEALTH SCIENCES

Transcription

1 Application No: MGM INSTITUTE OF HEALTH SCIENCES [Established u/s 3 of UGC Act, 956] Office : Post Box-6, Mgm Educational Complex, Plot No & 2, Sector-8, Kamothe, Navi Mumbai Ph. No. : , Fax : mgmuniversity@yahoo.co.in Website : Application for Pre-PhD Examination Recent Photograph of the Candidate with name and application no. (2.5 cm x 3.5 cm) Sign across the form & photo * Instructions for filling up the form:. Write with black ball point pen in the boxes using English Capital letters. 2. Fill appropriate circle in complete black ink wherever necessary. 3. While writing marks, exclude grace marks.. Surname / Last Name : (in block letters) First Name : (in block letters) Father s/husband s Name : (in block letters) Mother s Name : (in block letters) 2. Date of Birth ( dd/mm/yy ) : 3. Nationality : Indian NRI Other than Indian 4. Sex : Male Female 5. Religion : Caste : Blood Group : 6. Telephone No: 7. Mobile No: 8. Address : 9. Permanent Address: 0. Address :

2 . Qualifications: Attach attested copies of marklist in support of qualification. Qualification Board / University Year of Passing H.S.C. (0+2) or equivalent % Marks obtained Degree Course (Bachelor s Degree) Master s Degree 2. Preference for College of Admission : Preference College Code CODE COLLEGE MGM Medical College, Navi Mumbai 2 MGM Medical College, Aurangabad 3 MGM College of Nursing, Navi Mumbai 4 MGM College of Nursing, Aurangabad 5 MGM College of Physiotherapy, Navi Mumbai 6 MGM College of Physiotherapy, Aurangabad 7 MGM School of Biomedical Sciences, Navi Mumbai 8 MGM School of Biomedical Sciences, Aurangabad 3. Preference for Ph D Courses: Preference Course Code Course Code Name of Course 0 Ph D Medical Anatomy 02 Ph D Medical Physiology 03 Ph D Medical Biochemistry 04 Ph D Medical Pharmacology 05 Ph D Medical Microbiology 06 Ph D Medical Genetics 07 Ph D Medical Biotechnology 08 Ph D Hospital Management 09 Ph D Pharmaceutical Management 0 Ph D Physiotherapy Ph D Nursing

3 Declaration by the Candidate:. I hereby solemnly and sincerely affirm that the statement made and information given by me in the application form is true and correct. 2. 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. I understand that the selection and admission to the course is also liable to be cancelled. 3. I agree to abide by the Rules & Regulations and procedures as prescribed by University from time to time. 4. I undertake to submit all the required certificates at the time of my selection during admission process as per the rules, failing which may claim for selection shall not be granted. Signature of the Candidate I have fully read the information furnished by my son/daughter/ward and affirm that it is true, I understand that if it is proved that the information is fraudulent, I am liable to criminal prosecution. Signature of the Father/Mother/Guardian List of Documents required to be submitted: a. Marksheet, Passing Certificate and Attempt Certificate of School Leaving Certificate or any other authorized document clearly showing your date of birth. b. Marksheet, Passing Certificate and Attempt Certificate of Higher Secondary Certificate Examination or its equivalent examination from State board of Secondary & Higher Secondary. c. Marksheet, Passing Certificate and Attempt Certificate of Graduate degree examination or its equivalent from recognized University. d. Marksheet, Passing Certificate and Attempt Certificate of Post-Graduate degree examination or its equivalent from recognized University. e. Nationality Certificate. f. Brief research protocol: title, introduction, importance, research question of proposed research plan, objectives, methodology and references.

4 Application No: MGM INSTITUTE OF HEALTH SCIENCES [Established u/s 3 of UGC Act, 956] Office : Post Box-6, Mgm Educational Complex, Plot No & 2, Sector-8, Kamothe, Navi Mumbai Ph. No. : , Fax : mgmuniversity@yahoo.co.in Website : APPLICATION FORM FOR Ph. D. REGISTRATION Recent Photograph of the Candidate with name and application no. (2.5 cm x 3.5 cm) Sign across the form & photo To, The Vice Chancellor MGM University Of Health Sciences, Kamothe, Navi Mumbai. Through : The Dean Dear Sir, I am applicant for the Ph.D. Programme of the Institute. I am enclosing herewith my Biodata for your kind perusal and needful.. NAME IN ENGLISH (BLOCK CAPITALS): 2. ADDRESS FOR COMMUNICATION: 3. CONTACT NO & ID: 4. DATE OF BIRTH: 5. SEX (M/F): 6. IF EMPLOYED, DETAILS OF EMPLOYMENT: 7. RESEARCH EXPERIENCE (if any): 8. TEACHING EXPERIENCE (if any): Signature : (Name)

5 9. Proposed details for Ph. D Registration : Sl. No. i Particulars Title of proposed thesis Proposed Details for Ph. D. Registration ii iii iv Department in which the Candidate proposes to work and prepare thesis Institution in which the candidate propose to work and prepare thesis Name of Guide v Address for correspondence vi Phone : Mobile : Resi : vii Name of Co-Guide (if any) viii Address for correspondence ix Phone : Mobile : Resi : 0. Declaration by the Guide: I am a recognized Guide for the Ph D programme of MGM University as per the communication no dated. of the Registrar, MGM University. I undertake the responsibility of supervising Mr./Mrs./Ms for his/her Ph D. degree in the proposed field of research. The student is not related to me. The students who are Presently working for Ph D programme under my guidance are: Sl. No. Name of the Student Registering University Date of Registration Guide/Co-Guide

6 . Declaration by the Co-Guide : I am a recognized Co-Guide for the Ph D programme of MGM University as per the communication no dated. of the Registrar, MGM University. I undertake the responsibility of supervising Mr./Mrs./Ms for his/her Ph D. degree in the proposed field of research. The student is not related to me. The students who are Presently working for Ph D programme under my guidance are: Sl. No. Name of the Student Registering University Date of Registration Guide/Co-Guide Signature of the Co-Guide 2. Recommendation of the Head Of the Department : The Department of..of... work by. Under the guidance of. I Signature Name Department Seal 3. Recommendation of the Head Of the Institution : The Department of..of... work by. Under the guidance of. I Enclosures : Signature Name Department Seal Attested copy of the degree certificate of qualifying examinations. Attested copy of the mark sheet of qualifying examinations. Brief research protocol: title, introduction, importance, research question of proposed research plan, objectives, methodology and references. 4. Recommendation of the Head Of the Department :

7 The Department of..of... work by. under the guidance of. I The list of search facilities available in our department is attached. Signature Name Department Seal Note : Attach the list of research facilities available in the department required for the research work above candidate. 5. Recommendation of the Head Of the Institution : (Form the Candidate s Parent Institution. For External Part Time Candidates only) The Department of..of... work by. under the guidance of. I We will provide the research facilities required for the research work of above candidate. Signature Name Institution Seal Note : Attach the list of research facilities available in the department required for the research work above candidate. 6. I certify that the particulars given above are correct and I undertake to (a) abide by the rules of the Institution during the Ph. D. Programme. (b) appear before the relevant Committee whenever directed to do so, (c) appear any test or qualifying examinations as specified for the Ph. D. programme (d) If my admission is approved. I further request that I may registered for the Ph. D. programme, for which I shall pay any fees prescribed for the purpose. Yours faithfully, Signature (Name)