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p.g. admission form -2010

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p.g. admission form -2010 Powered By Docstoc
					            BHAVNAGAR UNIVERSITY
                Bhavnagar–364002
                     FACULTY OF MEDICINE

               APPLICATION FORM FOR ADMISSION
                   TO POST-GRADUATE MEDICAL
                 DEGREE AND DIPLOMA COURSES




           AT THE MEDICAL COLLEGE BHAVNAGAR

        AFFILIATED WITH BHAVNAGAR UNIVERSITY,
                      BHAVNAGAR.(GUJARAT)



WEBSITE : www.bvnmedicol.org.                  E-mail ID : dr_bd_parmar@yahoo.co.in
Phone No: 0278-2511511, 2516516                Fax : No. 0278-2422011




                                  (Price: Rs.200/-)
                                                              1
   FOR OFFICE USE ONLY-NOT TO BE FILLED IN BY THE APPLICANT
Application Reg. No.                                                      Sr. No.

Date of Receipt of Application

                                               Date               Month             Year

Status and Category :

Merit No.:

Name of Scrutiny Officer:

……………………………

Signature of Scrutiny officer

                                                                            Detail of Admission

                                                                            If admitted

                                                                            Subject …………………….

   1.   Admitted:………………………                                          MD/MS/Diploma Br………………………..
   2.   Refused ……………………….                                          Teacher …………………………..
   3.   No Vacancy……………………
   4.   Absent ……………………
   5.    Not eligible .....................................

   (A) Due to discrepancy in original
       Documents……………………….                                          ………………………………………
   (B) Due to admission taken in another
       Category …………………………                                          Name &
       ……………………………………                                               Signature of
                                                                    Admitting
                                                                    Authority ………. ……… ……..
                                                                    Date :   ……… ……….. …….
        Cheek list -
                                                             Signature & Name of officer
        1) Documents compared with original and found correct :……….       ………….
        2) Joined duty on :………….....Joining report received : ………..       ………….
        3) Shifted on :…………………Shifting report received:………..              ………….
         I do not wish to accept admission available to me.
         Date:…….......................     Signature of Candidate…………………………
                                            2
                             BHAVNAGAR UNIVERSITY
                              BHAVNAGAR.(GUJARAT)
                            Application form for admission to
                POST-GRADUATE DEGREE AND DIPLOMA MEDICAL COURSES
                         TO BE FILLED IN BY THE APPLICANT

         1 Full name of the Applicant :                                                        Affix
           (Fill in one letter in each square)                                             Passport size
                                                                                              Recent
         (a) Name                                                                           Photograph

         (b) Father’s / Husband’s Name


         (c) Surname




2 Sex : (Enter code No. in square) Male ………..1

                                                 Female………2

3 Date of Birth :                        Date          Month         Year

4 Place of Birth:
…………………………………………………………………………..
City /Village / Town                              District                  State
5 Address of applicant for correspondence :
…………………………………………………………………………..
………………………………………………….PIN…………………..
Email id:.....................................   PHONE NO………...…........ Mobile:.......................
Permanent (if other than above) address:
…………………………………………………………………………..
………………………………………………….PIN…………………..
                                                        PHONE NO………...………
                                              3

6 Nationality :………………………………………….

7 Parent's Occupation :………………………………….

8 Academic Year for which applied :                                                   2010



9 Information regarding STATUS :

  (Enter the code No. in the square)

       (1) Graduate from Bhavnagar University, under rule 4.1                          1
       (2) Graduate from Bhavnagar University,3 Year Standing under rule 4.2           2
       (3) + Graduate from other University of Gujarat State under rule 4.3            3
       (4) * Graduate from other University of Gujarat State, who has not joined
           P.G. Courses anywhere.(Degree/Diploma), under rule 4.4                      4

       (5) * Graduate from University outside Gujarat State.                           5

10 Category for which applied

       (Enter the code No. in the square )

       1) Open Merit
       2)  Scheduled Caste
       3) ST
       4) Socially and Economically Backward Community
          (Not included in creamy layer)
          (Cast / Category / once applied cannot be changed.)
       5) Physically handicapped
       6) In service Medical Officer.

            If applied for category 2,3,4 or 5 above give Caste in the square.

            Caste :                       Sub Caste :

(*) Eligible to apply only after obtaining Provisional Eligibility certificate from

   Bhavnagar University.

(+) The Medical College, from which candidate has graduated must be recognized by
Medical Council of India. So candidates are supposed to attach certificate from
concerned institute about M.C.I. Recognition status.
                                             4
(*) 11. Detail of marks obtained at various examination :

Examination    University    Date of starting   Date of result   Total aggregate      Attempts
                                 Exam           (Date of Mark    marks obtained       including
                                                sheet)           in Theory &          Drops
                                                                 Practical’s
                            Dt. Mth Yr          Dt   Mth    Yr    Marks obtained      Total
                                                .                Theory Pract.        out of
                                                                 Out of      Out of
III M.B.B.S.                                                                                   1
Part II                                                                                        2
                                                                                               3
                                                                                               4
                                                                                               Total
III M.B.B.S.                                                                                   1
Part I                                                                                         2
                                                                                               3
                                                                                               4
                                                                                               Total
II M.B.B.S.                                                                                    1
                                                                                               2
                                                                                               3
                                                                                               4
                                                                                               5
                                                                                               6
                                                                                               Total
I M.B.B.S.                                                                                     1
                                                                                               2
                                                                                               3
                                                                                               4
                                                                                               5
                                                                                               6
                                                                                               Total



@ In case of more than one attempt fill in attempt-wise marks, Include marks obtained in
subject of passing only. Total maximum marks of all attempts should equal total marks of
whole examination. Candidate should attach all mark sheets. (Pass, Fail)
                                                   5

For 11 and 12 (*) Non appearance in the university examinatation, when due, will be considered as failure
& attempt will be considered accordingly.

(*)12.Failures and drops Exam                    Date                     Failure or Drop

1)      …………………………                      ………………………….                       …………………………….

2)      …………………………                      ………………………….                       …………………………….

3)      …………………………                      ………………………….                       …………………………….

4)      …………………………                      ………………………….                       …………………………….

5)      …………………………                      ………………………….                       …………………………….

6)      …………………………                      ………………………….                       …………………………….

7)      …………………………                      ………………………….                       …………………………….

8)      …………………………                      ………………………….                       …………………………….

9)      …………………………                      ………………………….                       …………………………….

10)     …………………………                      ………………………….                       …………………………….

11)     …………………………                      ………………………….                       …………………………….

12)     …………………………                      ………………………….                       …………………………….

13)     …………………………                      ………………………….                       …………………………….

13. Date of admission in I M.B.B.S.     Date             Month                      Year



14. Mode of admission in I M.B.B.S.

        (1) “All India” basis 15 % reservation

        (2) H.S.C. Merit marks & Merit No. & attempt             Theory     Practical      English

           At Gujarat Board/Central Board Schools                Attempt             Merit No.

           Situated in Gujarat State.

        (3) Other                                        3.
                                                        Date          Month                     Year
15. Date of passing final M.B.B.S. examination
16. Internship completed on
17. Date of award of degree ( Convocation)
18. Have you applied for P.G. course before anywhere?                     Yes : 1
                                                                          No : 2
                                              6

If yes, give the detail in the following Performa:

University                           Bhavnagar               (Other specify)
Details

a.Date of Application
b. Application Reg.No.
c. Selected and joined
d. If selected and joined             Yes/No            Yes/No              Yes/No
the subject
f. No. and Date of
Registration
g. Date of completion of
course
h. Date of passing
I Present status
j. As stipendiary/ Non
Stipendiary / Floating
Resident or Tutor


19.    Detail of present Employment :

                     (a) Designation …………………………………..

                     (b) Place of working …………………………….

                     (c) Date of joined ……………………………….

20.    Detail of past Employment :

Designation                    Period for which held      Total period Year & Month
                               From …………..to ……….
(i)
(ii)




                                                     Signature of student
                                                         7
          Attested copies of the following relevant documents must be enclosed with application :
                                                                            Month & Year       Serial No.
(a) Mark sheets of all attempts of Final M.B.B.S. Part 2 Examination (a) ……………
                                                                     (b)……………..
                                                                     (c) …………….
                                                                        (d)…………….
(b) Mark sheets of all attempts of Final M.B.B.S.Part 1 Examination (a) …………….
                                                                    (b)…………….
                                                                    (c) …………….
                                                                    (d)…………….

(c) Mark sheets of all attempt of II M.B.B.S. Examination                                 (a)…………….
                                                                                          (b)…………….
                                                                                          (c) ……………
                                                                                          (d) ……………
(d) Mark sheets of all attempt of I M.B.B.S. Examination                                  (a) ……………
                                                                                          (b)…………….
                                                                                          (c) ……………
                                                                                          (d)....................
(e) Attempt Certificate of I,II,III (Part 1 and 2)M.B.B.S.
(f) Caste Certificate ( For category 2,3 & 4only)
            (For SC/ST /SEBC – certificate obtained from any of the competent Govt. authority viz.
                Collector, Prant officer, Mamlatdar/ Tehsildar / District Social Welfare Officer etc.,
            SEBC Candidate Have to Submit Non Creamy layer Certificate Not older than 1.4.2009
(g) Provisional Eligibility Certificate
    ( Essential for candidate from university other than Bhavnagar University)
(h) Internship completion certificate.
               For Clinical Subject : Applicant Must have Completed internship within previous 3 year or will
                complete it by on or before 31.3.2010 can apply
               For Non Clinical Subject: Applicant having internship completion older than last 3 calendar years
                can also apply.
(i) Degree certificate of M.B.B.S. (after convocation))
(j) Certificate of Registration (Provisional / Final) with Gujarat Medical Council
    (to apply within 1 month from the date of admission)
(k) Certificate from concerned institute about MCI Recognition of MBBS.
(l) School Leaving Certificate / SSC (10th ) passing certificate. (As a proof of birth date)
(m) Mark sheet of Higher Secondary or equivalent & Attempt Certificate .
(n) Registration Certificate of P.G. course
(o) Certificate of Completion P.G. Course.
(p) Passing /Degree certificate of P.G. Examination
(q) Selection intimation from D.G.H.S. Delhi (From “All India” candidates only)
(r) Two self addressed envelope (25 x 10 cms) with Rs 5 Postage stamp.


                                                                         Signature of Medical Student

                                                         8
         Govt. Medical College, Bhavnagar-364002
                         (Gujarat)
                                    Undertaking by the applicant


         1) I Dr.…….........………………………………………………………
            If any of the statement made in the application form or any
            information/document supplied by me in connection with my
            application for admission is letter on found to be false or in
            correct for misguiding or if It is found that I have concealed
            any information/fact in connection with my application, my
            admission shall be cancelled without any notice thereof, fees
            forfeited and I may be expelled and prosecuted.
         2) I Dr.............................................................hereby declare that
            I had not taken admission or registered for any P.G. Course
            (Degree/Diploma) in any institute in last 3 years
         3) I am aware that the permitted seat are subjected to approval
            from Medical Council Of India. In case of any cancelation by
            Medical Council of India, My admission is liable to cancel, for
            which Institute or University will not be held responsible.


Date:                                                                          Signature of Applicant
Place:                                                                         Address:
Mobile: E mail id:


In presence of Witness
 Name :..............................................Sign:....................................Date:.............................

				
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