All India Institute of Medical Sciences TEL : 911126588500, 911126588700, 911126589900 FAX : 911126588663, 911126588641 Registration Slip AIPGMEE 2012 MD/MS/PG Diploma Courses Application No. 8053053684 14.d) College from which passed College Name: Gandhi Medical College, Bhopal MBBS College Code: G090 Application Date 14Dec2011 State: 15 Madhya Pradesh 1) Course Applied MD/MS/PG Diploma Courses 15) Marks And Percentage in MBBS Max Marks: 2450 2) Community OBC Examination Marks Obtained: 1502 3) Physically Handicapped No Percentage: 61.31% 4) Sex Male 16.a) Permanent Registration Number 11153 5) Nationality Indian 16.b) Date Of Registration 05Jun2010 6) Name DHARMENDRA SINGH DANGI 16.c) Issuing Authorities of Registration 15 Madhya Pradesh 7) Father's Name HEM SINGH DANGI 17) Counselling Center Choice Delhi A1 8) Mother's Name KEDAR BAI DANGI 18) Phone No. 9) Date of Birth 25Feb1984 19) Mobile No. 9039120029 10) State Of Domicile Madhya Pradesh 20.a)Permanent Address VIVEKANAND COLONY 11) Exam Center Choice Bhopal SUGAR FACTORY CHOURAHA 11.1) Exam Center Code 03 SEHORE 12) Internship Status Completed 12.a) Internship Starting Date 31Mar2009 12.b) Internship Completiion Date 30Mar2010 20.b) State Madhya Pradesh 12.c) Number Of Months Of Internship 12 20.c) Pin Code 466001 13) Have Done Any PG No 20.d)Correspondence Address VIVEKANAND COLONY 14.a) Qualified From Degree from India University/Institute SUGAR FACTORY CHOURAHA 14.b) Qualifying Examination MBBS SEHORE 14.c.1) Year Of Admission Aug2004 14.c.2) Year Of Passing Examination 29Mar2009 20.e) State Madhya Pradesh Payment Details 20.f) Pin Code 466001 23.a) Mode Of Payment Challan 21) Mark Of Identification BLACK MOLE ON RIGHT CHEEK 23.b) Journal Number 005396770 22) Email Id email@example.com 23.c) Branch Code 0477 23.d) Payment Date 14Dec2011 24) Photo of Candidate 25) Signature of the Candidate UNDERTAKING: I undertake that I have completed/will complete 12 months Compulsory Rotating Resident Internship on or before 31032012. I solemnly affirm that the information furnished above is true and correct in all respects.l have not concealed any information. I realise that if any information furnished here in is found to be incorrect or untrue,I shall be liable to civil/criminal prosecution and also forgo my claim to the seat in the institute.Further,I affirm that no proceedings in respect of any civil/criminal offence alleged to have been committed by me are pending before any criminal court in India. I agree to abide by the rules and regulations governing this examination and as contained in the Prospectus. *Certified that I have informed the Head of my Institution/Department in writing that I am applying for this examination. I undertake that in the event to any communication from my Institution/Department withholding permission to my appearing in the above Entrance Examination/admission to the course, my candidature/admission may be cancelled. **I hereby declare that I belong to the OBC Community which is recognised as a backward class by the Government of India for the purpose of reservation for admission in Central Government Institution as per orders contained in Department of Personnel and Training Office Memorandum No 36012/22/93Estt. (SCT), dated 8/9/1993. It is also declared that I do not belong to persons/sections(Creamy Layer)mentioned in Column 3 of the Schedule to the above reffered office Memorandum, dated 8/9/1993, which is modified vide Department of Personnel and Training Office Memorandum No 36033/3/2004 Estt. (Res.) Dated 9/3/2004. I also declare that the condition of status/annual income for creamy layer of my parents/guardian is within prescribed limits as on financial year ending on March 31,2012. * Applicable for candidate persuing any PG Degree/Diploma Course/is employed, ** Applicable for candidate is belongs to OBC Community.