Part - I Particulars of Applicant: 1. Name (Full Name in Block Letters) 2. Date of Birth 3. Place of Birth 4. Address for communication

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1 RAJASTHAN AYURVED UNIVERSITY, (Only for Gen. & OBC Candidate) FM - 'A' S.No.... Reg. No.... Roll No.... Domicile of Rajasthan : No Yes Category... ADMISSION FM F BAMS/BHMS/BUMS COURSES IN AYURVED/HOMEOPATHIC/UNANI COLLEGES OF RAJASTHAN ( NO COLUMN TO BE LEFT BLANK. IF NOT APPLICABLE IT SHOULD BE MARKED"NA". USE CAPITAL LETTERS ONLY.) Part - I Particulars of Applicant: 1. Name (Full Name in Block Letters) 2. Date of Birth 3. Place of Birth 4. for communication Phone No. With code 4. Permanent (Only if different from for Communication) Part - II - Particulars of parents: Details Father Mother Name Occupation Annual Income Part - III - Particulars of Qualifying Exams: 1. Name of Exam. passed and year. 2. Name of Board/University: Subject Physics Chemistry Biology Total % Marks Max. Marks Marks Secured 3. Name of School/Institution last studied. Part - IV - Particulars relating to Admission Test: Choice for Center of Exam. (In order of Priority) NOTE: Center may be shifted in case number of candidates available at a center is less than 50. Sex: Male Female Category: (Tick those which are applicable) SC ST OBC GEN Phy. Handicapped ST/TADA Defence Personnel PASTE YOUR LATEST PASSPT SIZE PHOTOGRAPH DULY SIGNED BY YOU & ATTESTED BY A GAZZETTED OFFICER/PRINCIPAL OF INSTITUTE LAST ATTENDED

2 DECLARATION BY THE CANDIDATE 1. I have read the rules and regulations regarding Pre-Ayurved/Homeopathy/Unani Test and regarding Admission to the Ayurved/Homeopathy/Unani Colleges. I find myself eligible for the same. I realize that if the Admission Board decides that I am not eligible, I shall abide by its decisions. 2. I do solemnly affirm that the statement and information furnished by me as above and also in the enclosures submitted are true. I realize that, if any information furnished therein is found untrue in material particulars. I shall be liable to criminal prosecution as well as to forgo my admission and to be removed from the College, if already admitted. I shall abide by the decision of the Admission Board. 3. I also undertake to pay to the College, Hostel and other dues regularly. 4. I hereby agree, if admitted, to abide by the rules and regulations at present in force or those that may here after be made for the administration of the College and I undertake that so long as I am a student of the College, I will do nothing either inside or outside the College that will interfere with its orderly working and discipline. 5. I also declare that: (a) I have neither been convicted of any criminal offence, nor have been released on bail in connection with criminal case. (b) No case of criminal offence or moral turpitude is pending against me in any Court of Law. (c) No complaint or F.I.R. has been lodged against me by the University/Principal of a Constituent College/School. (d) I have not resorted to any act of indiscipline during the past year. (e) I have not been debarred from appearing in PAT/PHT/PUT I understand that if all the necessary documents are not appended with the form, the form is liable to be rejected. Place/Date: Note: Candidate must sign the Form failing which it will be rejected. F OFFICE USE ONLY (Candidate should not write anything) 1. Age on Information Fill Carefully Required Certificate Attached Years Months Dayes Yes/No 2. Applicant belongs to Rajasthan State Yes/No Yes/No 3. Sex: Male Female 4. Category Yes/No 5. Education Qualification Yes/No 6. Percentage of Marks in Optional subjects at the Qualifying Examination 7. Eligibility Requirements fulfilled Yes/No Yes/No 8. Remarks of Scrutiny Officer 9. Decision of Centralized Admission Board...

3 Eligibility Certificate I certify that Shri/kumari/Smt... Son/Daughter of...has studied for the last three years of the qualifying examination (X, XI & XII Classes) continuously as a regular candidate in recognized Institutions in Rajasthan and is an Indian National. of the Head Master/Principal Dated Head of the Institution last attended with Official Seal I certify that Shri/Kumari/Smt... is the natural Son/Daughter (not adopted) of Shri/Shrimati...and his/her Father/Mother has been continuously residing in Rajasthan for a period of 10 years and that he/she has studied for at least 5 years in this period in recognized educational institution in Rajasthan. of District Magistrate/ Dated Addl. District Magistrate Sub. Divisional Magistrate with Official Seal Certified that Shri/Shrimati... Father/Mother of Shri/Kumari... is a serving/retired, permanent employee of a Government Undertaking/Corporation/Improvement Trust/Municipal Board/Panchayat Samiti/Co-operative Bodies, a University/Board of Secondary Education duly constituted by the Government of Rajasthan by an act of Law who has put in atleast three years of service on the last date of submission of the application in the year of admission. He/she is in service as...in the... since... (Designation) (Office/Deptt.) of the Employer Dated Head of the Department with Designation and Seal. The candidate should submit his/her Bonafide Resident certificate issued by the Competent Authority of Government of Rajasthan. Note: Any of the above four certificates is necessary, for those candidates who seek admission in Ayurved Courses. However, admission in Ayurved Course of NIA is done on India Level Merit and these certificates are not required.

4 FM B : EXAMINATION CUM APPLICATION FM S.No. Registration No. Roll No. (Candidate should leave this blank) 1. Name Mother s Name Initial letters Initial letters PASTE YOUR LATEST PASSPT SIZE PHOTOGRAPH DULY SIGNED BY YOU & ATTESTED BY A GAZZETTED OFFICER/PRINCIPAL OF INSTITUTE LAST ATTENDED 4. for Correspondence 5. Date of Birth Date month year 6. Sex Male Female 7. Reservation Category SC ST OBC GEN TADA DEF 8. Orthopedic Physically Handicapped YES NO 9.Whether qualifying exam already passed or appearing in 2010 Already passed Shall appear in Percentage of marks in qualifying exam (if already passed). % 11. Centre Choice I (In Order of preference) II III Attendance Record (To be Used in the examination hall) Time Subject of Candidate of Invigilator 8.00 AM AM Physics & Zoology AM PM Chemistry & Botany

5 RAJASTHAN AYURVED UNIVERSITY OFFICE COPY PAT/PHT/PUT 2010 _ RAJASTHAN AYURVED UNIVERSITY COPY OF SUPERINTENDENT OF CENTRE To be obtained during admission test PAT/PHT/PUT 2010 _ RAJASTHAN AYURVED UNIVERSITY CANDIDATES COPY PAT/PHT/PUT 2010 _