ADMISSION TO MBBS/BDS COURSE 2008-2009 SESSION COMMON APPLICATION FORM (GENERAL CATEGORY) SELECTION COMMITTEE DIRECTORATE OF MEDICAL EDUCATION RANDOM NUMBER APPLICATION REGISTRATION NUMBER (To be assigned by Selection Committee) 1. +2 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 1 2 3 4 5 8. 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
9. DATE OF BIRTH 10. COMMUNITY (ENCIRCLE A CODE) DATE MONTH YEAR O.C B.C. BCC BCM MBC/DC S.C. S.T. 1 2 3 4 5 6 7 11. 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 1 2 3 4 1 2 3 15. 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
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 1 2 3 4 5 6 SCHOOL PLACE 1 2 3 4 5 6 24 OCCUPATION OF PARENT / GUARDIAN (ENCIRCLE A CODE) STATE CENTRAL PROFESSIONAL INDUSTRY BUSINESS AGRICULTURE PRIVATE SMALL OTHERS GOVERNMENT GOVERNMENT ORGANI- TRADE SATION 1 2 3 4 5 6 7 8 9 25. AVERAGE MONTHLY INCOME OF PARENT / GUARDIAN (ENCIRCLE A CODE) BELOW Rs.3000 Rs. 3001-5000 Rs. 5001-8000 Rs. 8001-12000 Rs. 12001-17000 Rs. 17001-21000 ABOVE Rs.21000 1 2 3 4 5 6 7 26. 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
27. DECLARATION BY THE APPLICANT I... (Name in full and in Block Letters) SON/ DAUGHTER WARD of.. an applicant for MBBS / BDS course 2008-09 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
A.R. No. : ACKNOWLEDGEMENT CARD The receipt of your application for admission to M.B.B.S. / B.D.S. DEGREE COURSE 2008-09 SESSION IS ACKNOWLEDGED Secretary Selection Committee Chennai - 600 010. * Write your mailing address and affix postal stamps to the value of Rs. 6.00 on the reverse in the space provided. Affix Rs. 6.00 Postage Stamp To............ PINCODE
INFORMATION OF MEDICAL / DENTAL COLLEGES FOR 2008-2009 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: 044-25305000 Central Rly. Station ½ Km Madras Medical College, Fax : 044-25305115 Park Town Bus Stand ½ Km Yes Yes Periyar EVR Road Park Town, Chennai - 3 2. Dean, Std Code 044 Washermenpet Rly Station, Yes Yes Stanley Medical College, Ph:25281346 with in a km M.C. Road, Fax : 25283173 Bharathi Arts College for Chennai - 1 Women stop, Walkable Distance 3. Dean, (0452) Madurai Railway Station Yes Yes Madurai Medical College, Ph. : 2532535 to 42 (Junction) 3 Kms Panagal Road, Madurai 625 020. Fax : 2526028 Anna Bus Stand ½ km 4. Dean, (04362) Thanjavur Railway Station 5 Kms Yes Yes Thanjavur Medical College, Ph: 240854 New Bus Stand 3 Kms Thanjavur, Pin-613004. Fax: (04362) 240854 Old Bus Stand - 5 Kms 5. Dean Std - 044 KMC Bus Stop (Walkable Yes Yes Kilpauk Medical College Ph: 26431930 distance) Poonamallee High Road, 26412979 Park, 3 Kms Kilpauk, Chennai - 600 010. 26431927 Central, Egmore - 3 Kms Fax : 28364950 Chetpet - 1km. 6 Dean Ph. & Fax. Chengalpattu Jn. 3 Kms Yes Yes Chengalpattu Medical College, 044-27426566 Chengalpattu Bus Stop 3 Kms. Chengalpattu - 603 001 Kanchipuram Dist 7. Dean Ph. : 0462-2572733 Tirunelvely Railway Station 6 Kms Yes Yes Tirunelveli Medical College, 2572734, 2572944 Nearst Bust Stop Tirunelveli, Pin - 627 011 Fax : 0462-2572944 High Ground ½ Km, New Bus stand 8. Dean Ph. : (0422) Coimbatore Junction 10 Kms Yes Yes Coimbatore Medical College 2574375 Medical College Bus Stop Avinashi Road, 2574376 (College Opposite) Peelamedu, Fax : 0422 Coimbatore - 641 014 2574377 9. Dean (0427) 2383313 Salem Junction 7 Kms Yes Yes Govt. Mohan Kumara Fax : (0427) Nearest Bus Stop Mangalam Medical College 2383193 Medical College Bus stop Salem, Pin - 636 030. 59
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. 2401011 Bus Stop Medical College, Fax : 0431-2411012 Medical College entrance Pariyamilaguparai Bus Stop Less than ¼ Km Tiruchirapalli - 620 001. 11. Dean, Ph:(0461) 2392698 Thoothukudi, Rly, Station 6 Kms Yes Yes Thoothukudi Govt. Medical Fax : 0461-2310122 Old Bus Stand - 4 Kms. College, 3rd Mile, Kamaraj Nager Thoothukudi - 628 008 12. Dean, Ph:04652 Nearest Railway Station Yes Yes Kanyakumari Government 223201, 223202 Nagerkiol - 6 Kms. Medical College 229942 Vadasari Bus Stand - 6 Kms Asari Pallam - 629 201 Fax : 223201 & Nagercoil Bus Stand - 6 Kms K.K. District. 245176 13. Dean, (0416) Katpadi Railway Station 15 Kms Yes Yes Govt. Vellore Medical College, 2260900 Vellore Bus Stop - 10 Kms Vellore - 11. Fax : 2261900 14. Dean Ph. 04546 Theni Yes Yes Govt. Theni Medical College, 244402, 244503 Medical College Theni - 625531 243603, 243602 Bus Stop ½ Km Fax :04546-244502 15. Dean Ph. : 04294 Erode - Rly. Station 22 Kms. Yes Yes IRT Perundurai Medical College, 220910 to 220913 Bus Stop. Perundurai - 2 Kms. Perundurai, Sanitorium-638 053. Fax : 04294-220226 Erode District, 16. Principal Ph. : 0422 Coimbatore Central Yes Yes P.S.G. Institute of Medical 2570170-7 Lines Railway Station - 7 Kms Sciences & Research 2598822-16 Lines Peelameeju Bus Stop - 100 Mts. Post Box No. 1674 Fax : 0422-2594400 Avanashi Road, Peelamedu, Coimbatore - 4. 17. The Director Ph. : 04651 Kuzhithurai Railway Yes Yes Sree Mookambika Institute of 280866 Station - 12 Km Medical Sciences Bus Stop Kulasekharam Velayuthan Pillai Memorial Fax: 04651-280740 100 feet. Hospital Complex, Padanilam, Kulasekharam- 629 161 K.K. District. 18. Dean Ph. : 044 Tambaram Railway Yes Yes Chettinad Hospital & 27475123, 27475577 Station 25 Kms Research Institute 27475959, 27475995 Bus Stop -Kelambakkam 2 Kms I.T. High Way, Fax : 044-27475970 Kelambakkam, Padur, Kanchipuram Dist - 603103 60
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. 25341342 Dental Hospital Bus Stop Dental College & Hospital 25340343 adjacent to the College entrance Dr. Muthusamy Road, 25340441 Chennai - 600 003. Fax : 044-25340681 Opp. to Fort Rly. Station 20. The Principal Ph:(044) Tambaram Railway Yes Yes Ragas Dental College & Hospital 24530002 to Station - 15 Kms 2/102, East Coast Road, 24530006 College Bus Stop - 20 feet Uthandi, Chennai - 600 119 Fax: 044-24530009 21. The Principal Ph:04288 Erode Railway Station - 10 Kms Yes Yes J.K.K. Nataraja Dental 260203, Komarapalayam - Vattamalai College & Hospital 260322 Bus Stop. Komarapalayam - 638 183 Fax :04288-265793 Namakkal Dist. 22. The Director, Ph. : 04651 Kuzhithurai Railway Yes Yes Sree Mookambika Institute of 280745 Station - 12 Km Dentall Sciences 280742 Bus Stop Kulasekharam Velayutham Pillai Memorial Fax: 04651-280740 100 feet Hospital Complex, Padanilam, Kulasekharam- 629 161 K.K. District. 23. The Principal, Ph. 04637 Nearest Railway Station Yes Yes Rajas Dental College & Hospital 230163, Valliyoor - 20 Kms. Thirurajapuram, 292488, 292489 Nagercoil - 25 Kms. Kavalkinaru Junction, Fax :04637-231367 Kavalkinaru Junction Tirunelveli Dist - 627105 Walkable distance 24. The Principal Ph. : 04288 Erode Railway Station - 12 Kms Yes Yes K.S.R. Institute of Dental 274745/ 274741-44, Opp College KSR Science & Research 274981 Kalvi Nagar on Thokkavadi Post, Fax : 04288-274761 Erode - Tiruchengode Tiruchengode - 637 215 Namakkal Dist. 25. The Principal Ph. : 0422 Nearest Railway station Yes Yes Sri Ramakrishna Dental 2560381 Coimbatore 6 Kms. College & Hospital Fax : 0422-2564688 Nearest Bus stop S.N.R. College Road, Nava India - 0.5 Kms. Coimbatore -641 006 26. The Principal Ph. : 044 Melmaruvathur Railway Yes Yes Adhiparasakthi Dental 27529628 Station ½ Km from College College & Hospital 27529230 Bus Stop ½ Km from College Melmaruvathur, Fax: 044 Kanchipuram Dist - 603 319 27529393, 27529628 27. Principal, Ph. : 044 Nearest Railway Station Yes Yes Sri Venkateswara Dental 27435060-61 Velachery - 9 Kms. College & Hospital Fax : 044-27435059 Bus stop - Thalambur - 100 Mts. Opp. Old Mahabalipuram Road Thalambur Village, Kancheepuram Dist. 61
Phone Nos. Nearest Hostel Facilities No. College Address & Railway Station/ Availability for Fax No. Bus stop Boys Girls 28. The Principal Ph: 04288 Nearest Railway Station Yes Yes Vivekananda Dental College 234674 (4 Lines) Erode - 25 Kms for Women 234890 & 91 Nearest Bus Stop Elayampalayam - 637205 Fax: 04288 Tiruchingode - 6 Kms. Tiruchengode (TK) 234890, 234891 Namakkal Dist 29. The Principal Ph:0452 Nearest Railway Station Yes Yes Best Dental Science College 2534593, 2423291 Madurai Junction - 12 Kms. Ultra Trust, No.69/1A Melur Road Fax : 0452 Bus Stop -Mattuthavani - 4 Kms. Vowalthottam (P.O.) 2539828 Madurai - 625 104 30. The Principal Ph. : 044 Nearest Railway Station Yes Yes Karpaga Vinayaga Institute of 27598484 Chengalpet - 15 Kms. Dentall Sciences, 24735716, 24735736 Nearest Bus stop GST Road, Palayanoor Post, Fax : 044-27592844 Padalam - 1 Km. Chinnakolambakkam, Madhuranthagam Taluk, Kancheepuram. District - 603 308 31. The Principal, Ph. 044 Nearest Railway Station Yes Yes Priyadharshini Dental 27650161, 27650364 Thiruvallur - 6 Kms. College & Hospital 27650464, 27650488 Nearest Bus Stop Pandur 1, VGR Gardens, VGR Nagar, Fax : 044-27650160 Pandur - 631 203, Thiruvallur TK & Dist. 32. The Principal Ph. : 044 Nearest Railway Station Yes Yes Madha Dental College& Hospital 24780736 Pallavaram - 8 Kms. Madha Nagar, Fax : 044-24780798 Nearest Bus Stop Somangalam Road, Kundrathur - 1Km. Kundrathur, Chennai - 600 069 33. The Principal Ph. : 0452 Nearest Railway station Yes Yes CSI. College of Dental 2371708 Madurai Junction 2 Kms. Scicnces and Research Fax : 0452-2336605 Nearest Bus stop 129, East Veli Street, Front of College Madurai -625 001. 34. The Principal Ph. : 044 Nearest Railway Station Yes Yes Chettinad Dental College & 27475090, 27475995 Vanadalur - 14 Kms. Research Institute Fax: 044 Bus Stop Kelambakkam - 500 Mtrs. I.T. High way, Kelambakkam, 27475970 Kanchipuram Dist - 603 103 35. The Principal Ph. : 044-69904863 Nearest Railway Station Yes Yes Tagore Dental College & Fax: 044-27477702 Vanadalur - 7 Kms. Hospital Bus Stop Rathinamangalam - 1/2 Km. Rathinamangalam, Vandalore P.O., Chennai - 48. 35. The Chairman, Ph. : 0431-3205736 The Trichy Rajas Dental Fax No. : 0431 College & Hospital 2680295 Raja Nagar, Nagamangalam Tiruchirapalli - 620 012. 62
# MBBS / BDS Course ADMISSION 2008-2009 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 1.1 +2 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