Docstoc

508257

Document Sample
508257 Powered By Docstoc
					                                                                               1/2
               JAWAHARLAL INSTITUTE OF POST GRADUATE MEDICAL EDUCATION AND RESEARCH, PUDUCHEERY- 605 006.
                            Online Application form for Admission to Jipmer MD/MS Courses-April 2012 Session.
                           Last Date for receipt of completed Application is 12th January 2012 before 5:00 PM.

                                                                                                                         508257
                                                                                                                                          -
                                                                                                      App. No.:                                       NEW DELHI
     Paste here firmly your recent
       photograph 4cm x 5cm.

      Do not get the photograph
              attested.
                                                                                                                                                           DDP

     Do not staple the photograph.                                                        508257




                                                                                                                        Signature of the Candidate.
1.     Name (as given in X / XII Std / MBBS Certificate):                                          DHARMENDRA SINGH DANGI

2.     Son/Daughter of:                                                                            HEM SINGH DANGI

3.     Category:                                                                                   OBC

4.     Whether OPH (Refer Prospectus)(Enclose attested copy of the Medical Certificate             No
       incase of OPH candidates)
                                                                                                   25/Feb/1984
5.     Date of Birth:

6.     Date / Expected date of completion of internship training:(Note:INTERNSHIP                  30/Mar/2010
       have been completed by 31.3.2012-else ineligible)

7.     Gender:                                                                                     Male

8.     Is your MBBS Degree recognized by MCI?                                                      Yes

9.     Are you a service candidate? If yes the forwarding Note of the Employer is to be            No
       filled as in the overleaf:

10. Address for Communication:                                                                     VIVEKANAND COLONY
                                                                                                   SUGAR FACTORY CHOURAHA
                                                                                                   SEHORE
                                                                                                   SEHORE
                                                                                                   466001


11. Phone No. with STD Code:                                                                       07562                  265465

12. Mobile No.:                                                                                    9039120029

13. Email Address:                                                                                 DR.DHARMENDRADANGI@GMAIL.COM

14. Month and Year of passing MBBS:                                                                MAR 2009

15. Name of the College last studied:                                                              GANDHI MEDICAL COLLEGE

16. Name of the University last studied:                                                           BARKATULLAHA UNIVERSITY

17. Payment particulars:
                                                                                                   1000
      Amount:
                                                                                                   002120
      DD / Trans No.:
                                                                                                   20/Dec/2011
      Date of Payment:
                                                                                                   IDBI BANK
      Bank:
                                                                                                   SEHORE
      Place:
                                                                                                   NEW DELHI
18. Centre for Examination:
                                                                                                   Neither Graduate
19. Parent's Educational Background:
                                                                                                   AGRICULTURE
20. Parent's / Guardian's Occupation
                                                                                                   50,000 to 1,00,000
21. Parent's / Guardian's Total Annual Income:
                                                                                          2/2
               JAWAHARLAL INSTITUTE OF POST GRADUATE MEDICAL EDUCATION AND RESEARCH, PUDUCHEERY- 605 006.
                            Online Application form for Admission to Jipmer MD/MS Courses-April 2012 Session.
                           Last Date for receipt of completed Application is 12th January 2012 before 5:00 PM.


App. No.:                         508257

Name :                            DHARMENDRA SINGH DANGI
                                                                    DECLARATION BY APPLICANT
                                                                      ( Applicable to all courses )
1.        I hereby declare that the application has been filled in my own handwriting and all statements made in it are true, complete, and correct to the best of my
          knowledge and belief and nothing has been concealed. In the event of any statement being found false or incorrect or any ineligibility being detected
          before or after the selection, action such as removal of my name from the rolls and / or other action as may be considered necessary can be taken
          against me.

2.        I also declare that I have carefully read the contents of the Prospectus in respect of the course applied for by me and undertake to abide by the provision
          contained therein. I undertake to submit all the required certificates including proof of category in original at the time of counseling as well as at the time
          of admission if, selected.

3.        I shall maintain proper dress code during counseling and admission.

4.        I further declare that I fulfill all the eligibility conditions regarding educational qualification, experience etc.

5.        I accept that any misconduct / malpractice, if detected in me, during Entrance Exam will render me liable to legal action by JIPMER authorities.

6. If selected :
  (A) I agree to work on whole time basis:
  (B) I shall not engage myself in private practice or part time job during the period.
  (C) I shall not draw any pay, fellowship or any kind of monetary assistance from any
  other sources, if I am allowed emoluments by the Institute.

7.        I hereby represent and attest that the picture in this application form are a true and accurate representation of me and that I am the same person
          identified in this application for the course mentioned therein




Place ..............................................
Date ...............................................

                                                                                                                             Signature of Applicant in running hand
                                                                    IMPORTANT INSTRUCTIONS
                                                                          ( Please Note )

     1.      Keep the xerox copy of the application after filling all the details for any future reference.

     2.      DD should be in the name of "Accounts officer, JIPMER payable at PONDICHERRY, Union Territory" incase of DD payment. Fee Once Paid will not
             be refunded.

     3.      Failure to post this printout duly signed with the BankDD or NEFT/SBI Payment details, copies of OBC/SC/ST/OPH certificates will lead to rejection of
             the application

     4.      Please Speed Post to Professor (Academic), JIPMER, PONDICHERRY - 605 006. Last date for the receipt of completed application : 12-01-2012
             before 5:00 PM.

     5.      Application should necessarily be accompanied with an attested copy of the OBC / SC / ST / OPH certificate (wherever applicable). The certificate
             should have been issued by the Competent Authority.

     6.      Application without the OBC / SC / ST / OPH certificate would be considered only under the General Category.

     7.      Change in category after submission of application would not be considered under any circumstances.

     8.      No communication would be entertained in this regard.

     9.      Please attach Recent Color passport size photograph with Name and Date of Photograph.

     10. Please attach Demand Draft in Original in case of DD Payment

     11. Please attach Photocopy of OBC / SC / ST as proof of Category

     12. Please attach recent copy of Medical certificate with percentage of disability in case of OPH.

             Your queries will be answered only in this number Ph : 044-4350 0822, 044-4350 0922.

                                                                           * * *     E n d   o f   O L A    * * *  

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:0
posted:4/16/2012
language:
pages:2