application form by qvi49I

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									Application Form No.

                       Terna Public Charitable Trust’s
TERNA MEDICAL COLLEGE & HOSPITAL
      Sector-12, Phase-II, Nerul,Navi Mumbai -400706 Ph.27720563
===============================================
Application for the Diploma Course in_______________

                                     AUGUST 2012
To,
The Dean,
Terna Medical College
Nerul,Navi Mumbai

Name:__________________________________________________________________
(Capital Letter) (Surname)       (First Name)        (Father’s/Husband’s)

Date of Birth: _________________________________________________________

Present Address
________________________________________________________________________

________________________________________________________________________

Tel.No._____________________________Mob:________________________________

Permanent Address
________________________________________________________________________
________________________________________________________________________

Tel No __________________Mob:__________________________________________

Nationality: ___________________Marital Status_____________________________
Qualification:____________________________________________________________

Institute:________________________________________________________________

Whether the institute is recognized by MCI :Yes /No.
Educational Qualification:
 Exam              College/Institute  Attempt      University   Year for
Passing              Percentage
__________________________________________________________________________
I MBBS __________________________________________________________________

II MBBS
III MBBS (Part-I)

III MBBS(Part-II)



                                 _________________________
*Additional Qualification (if any)

* Internship (Duration) from _________________to____________________________

* Maharashtra Medical Council (Permanent)Registration No _________Date_____

* Are you bonded candidate by Govt. Yes/No

* Enrolment for any other diploma Course else where
 (Specify)________________________________________________________________

Applied for:_____________________________________________________________
(In order of preference_ Details of first preference subject)


Final MCPS/MBBS marks: _____________out of______ Attempts______________

Ist Preference subject marks: ___________out of ______Attempts_______________


                     Details of Second preference subject

Final MCPS/MBBS marks:_ ____________out of _______Attempts______________

 IInd Preference subject marks:_______out of ________Attempts_______________




                      Details of Third preference subject
Final MCPS/MBBS marks: ________________out of ___________ Attempts______

III rd Preference subject marks: _______out of ________Attempts______________



For Office use only:-
C.OTHER INFORMATION:-
Post held if any a) At present:-_________________if Yes, give details_____________
                  b) Past ______________________if yes give details______________
                c) Employed by State Govt./Zilla Parishad/Corporation etc. if any –
                   If Yes-specified Prizes / Scholarships/Distinction if any: _____
P. G. Registration held in any subject:- Yes / No
If yes details :-
________________________________________________________________________

Two reference with address:-

1)_____________________________________         2)_____________________________

_____________________________________             ____________________________

 ______________________________________           _____________________________
_______________________________
Tel. No.________________________________           Tel.No.____________________

Place:________________________________

Date:-                                                             Signature

I____________________________________________agree with all rules and regulations.
hereby declare that all information given by me in this application is true and if found
inform it.

I am responsible and I shall be liable for any punishment ,including cancellation of
Enrollment.


 Date:                                                             Signature:

List of the documents (Attested Xerox Copies) to be submitted along with this

application form.

  1) Birth Certificate / S.S.C. certificate.

  2) MBBS Passing Certificate

  3) MBBS degree certificate

  4) Internship complication certificate (University)

  5) M.M.C. Registration Certificate (Permanent)

  6) Submit the details at present employer ie, name of the employer, Designation

   ,place posting duration of post etc.

  7) NOC from present employer.

								
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