KLE UNIVERSITY. Duration: 3 Years & 6 months Internship Courses : I hereby apply for admission to the

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1 KLE UNIVERSITY (Formerly known as KLE Academy of Higher Education & Research) [Established under Section 3 of the UGC Act, 1956 vide Government of India Notification No.F.9-19/2000-U.3(A)] Accredited A Grade by NAAC (2 nd cycle) Placed in Category A by MHRD (GoI) Office of the Registrar, KLE University, JNMC Campus, Nehru Nagar, Belagavi , Karnataka State, India : FAX: Web: Constituent College of the University: J.N.Medical College, Nehru Nagar, Belagavi Ph. No , FAX No. : Website: Application form for Admission to B.Sc. Allied Courses ( ) 1. Medical Lab. Technology 2. Radiography Duration: 3 Years & 6 months Internship Courses : 3. Cardiac Care Technology 4. Perfusion Technology 5. Anaesthesia Technology 6. Neuro- Science Technology SPACE FOR PHOTOGRAPH To The Registrar, KLEUniversity, JNMC Campus, Belagavi Sir, I hereby apply for admission to the B.Sc. Allied Course of KLE University, Belagavi and request for enrolment as a B.Sc._ course in its constituent college viz., J. N. Medical College, Belagavi. I am herewith furnishing the following information. Kindly do the needful. Yours faithfully, Place: Date: (Signature) (Name) 1

2 PARTICULARS OF THE CANDIDATE 1) a) Name of the applicant. (In full and BLOCK letters) b) Name of Father/ Mother/ Husband: 2) Address for correspondence PIN Code: Permanent Address 3) Date of Birth and Place Gender Blood Group Telephone No.(Resi.) with code 4) Mobile No. (Mandatory) Alternate Mobile No 5) E - Mail (Mandatory) 6) a) Nationality : b) Religion : b) Mother tongue : d) Caste / Sub Caste : 7) (a) Name of Parent / Guardian (b) Occupation (c) Annual Income Telephone No.(Resi.) Telephone No.(Office) 8) Last College / Institution attended: Date of Leaving: Course Studied: 9) Information about Foreign Students: a)country / Citizenship : (With supporting documents) b) Passport No. Date and place of issue : c) Kind of VISA : d) Permanent residence Address (abroad) 2

3 11) Details of Examinations Passed: Examinations Name of the Institution & Name of the Examining Board or University No. of attempts Month & Year of Passing Total secured in all subjects Max Obtd. Science Subjects Studied in each Subjects Max Obtd. Percentage of Obtd. in Science Group & English a) SSLC /XthStd Science b) I PUC Physics Chemistry /XI Std/ Biology c) II PUC Physics Chemistry /10 +2/XII Biology English d) Certificate /Diploma a) S.S.L.C / Matriculation / Senior Cambridge / Higher Secondary Certificate. b) Pre- University Science / First Year Science (if passed two year P.U.C Examination give marks obtained at the 2 nd year) c) Pre- Professional Course / Pre-Medical / Intermediate Science / 1 st Year. d) Paramedical certificate course marks /Paramedical Diploma course marks and certificates Note: 1) Enclose photo copies of certificates wherever necessary. 3

4 12) Extracurricularactivities (during the last two years preceding the year of application for admission): a) N.C.C / Home Guard / Girls Guide: after passing S.S.L.C b) Sports ( Cricket, Foot Ball, HockeyTennis, Badminton, Volley Ball, Basket Ball, Swimming, Kabbaddi, Kho-Kho and Athletics): c) Literary Activities: d) Other Extra Curricular Activities: 1. Each downloaded application form must be accompanied with Application form fee of Rs. 500/- in the form of Demand Draft drawn in favour of the "Registrar, KLE University, payable at Belagavi". Application Form Fee is not refundable. 2. Applications which are incomplete and contain incorrect information and not accompanied by the required certificates and Demand Draft towards downloaded Application Form Fee will be rejected. The applications received after the due date will also be rejected. 3. Candidates if called for written test/interview by the authorities, should appear at the specified place, date and time at their own cost. IMPORTANT INSTRUCTIONS 1) On admission to the College the student has to pay tuition and other fees for the whole year. Fees once paid will not be refunded or adjusted. 2) Transfer / Migration certificate in original must be produced at the time of admission with other certificates. 3) It shall be the responsibility of student of other Universities / Board to produce the Eligibility Certificate from the KLE University, Belagavi before taking admission. 4) If any information furnished in the application or any documents submitted in connection with admission to the said course is found subsequently incorrect or false or fraudulent, he /she is liable for prosecution for submitting false / wrong information as per the law in force. If, on any account my admission is cancelled by reason of any act of Government or the University, I shall not claim damages or compensation from the college and University. 5) Change in address (Local or Permanent) should be intimated to the college immediately. 6) All the candidates are required to produce the Eligibility Certificate obtained from the Registrar, KLE University, Belagavi, about their eligibility to the B.Sc. Course before taking admission. 7) Foreign students are required to get clearance and permission from the Ministry of Health and Family Welfare, Government of India, New Delhi before taking admission. Place: Date: Signature of the Applicant 4

5 DECLARATION BY THE APPLICANT 1. I hereby agree, to abide to the rules and regulations at present in force or that may be hereafter framed for the governance of the college and its attached Hospital and Hostels, and I undertake that so long as I am a student of the College, I do nothing either inside or outside the College and Hospital that will interfere with the orderly governance and discipline. 2. I hereby agree to make good if any loss or damage to books, apparatus, furniture and other belongings to college and its attached Hospital and Hostels, which may be caused by my carelessness, negligence or wantonness on my part. 3. I hereby solemnly affirm that the statements made and information furnished in my application form and also enclosures there to submit by me are true. Should it however be found that any information furnished therein is untrue in material particulars, I realize that I am liable to criminal prosecution and I also agree to forgo my seat in the college. 4. I hereby declare that I will not seek transfer from this college to any other college till I complete the entire course in this college and bind myself to the rules that are in force and that may be framed hereafter, in this connection. I also undertake to pay the remaining course fee if discontinued. 5. I hereby assure that I will not indulge or resort myself in any form of anti-social and prohibitive activities such as RAGGING or any kind of harassment-physical or otherwise. I am fully aware of the provisions of Indian Penal Code relating to the offences connected with hurt, endangerment of life or personal safety, wrongful confinement, assault, criminal intimidation and so on and if I am found indulging myself in such prohibitive and anti-social activities, I am liable for severe punishment including removal from the college and handing over to the Police. 6. I agree to pay the full course fees in case I want to discontinue before the expiry of the course or wants to seek transfer to any other college. 7. I am aware that the University has the full authority to expel me for disinterest in studies, misbehavior and continuous failure. If I am expelled from the University for any reason whatsoever, my stay in the College or Hostel shall be unauthorized and I am liable for disciplinary action as per the rules of the institution. 8. I shall cease to be the student of the institution if, any time I go on strike or absent myself from the classes during the period of strike or violate any rules / regulations of the institution. 9. If I am found at anytime in possession or in custody of arms weapons including rods, chains, swords, etc., within the premises of the college and hostels, I am liable to be expelled from the college at the discretion of the college authorities. 10. I am aware that I am liable for disciplinary action including removal from the hostel and the college, if the college, authorities find me under drug / alcoholic influence. I hereby declare that I abide by the above mentioned rules. Date: Place: (Signature of the applicant) 5

6 DECLARATION BY THE PARENT / GUARDIAN I affirm the above undertaking made by my Son / Daughter / Ward. I am admitting him/ her to the B. Sc. Allied Course at J.N.Medical College, Belagavi with understanding that he / she will diligently obey the above conditions. I also hereby declare that I hold myself responsible for the timely payment of all dues payable to the J N Medical College, Belagavi in respect of my ward Mr./Ms during the period of his/ her study and disciplinary behavior of my ward and abide by condition No.4 of the declaration signed above by my son / daughter / ward. In case the candidate wants to discontinue before the expiry of the course or wants to seek transfer to any other college, I take responsibility of payment of fees of all the remaining years of the course. Place: Signature of the Parent / Guardian Date: ===================================== FOR OFFICE USE Admitted to Fee paid vide Receipt No. Date: of Rs. for full course. Belagavi. Date: Finance Officer: Registrar KLE University Obtaining Eligibility Certificate by the University before making admission: No Candidate shall be admitted for any graduate/degree/diploma course unless the candidate has obtained and produced the eligibility certificate issued by the University. Candidates should obtain the eligibility certificate before the last date for admission as notified by the University. Verified by 6

7 CERTIFICATE OF PHYSICAL FITNESS TO BE ISSUED BY A REGISTERED MEDICAL PRACTIONER I hereby certify that I have examined Mr / Ms a candidate for selection to the B.Sc. Allied course in Jawaharlal Nehru Medical College, Belagavi and cannot discover that he / she has disease, constitutional affliction or body infirmity except I do not consider the disqualification for undergoing the above course of studies in J.N.Medical College. His / her age by appearance is years. He / She has the following marks of identification: a) b) Personal marks of identification: a) Height b) Weight c) Chest measurement on full inspiration and expiration d) Acuteness of vision Right Eye Left Eye Trachoma N.B. Any defect, deformation or other disabilities if present should be mentioned in detail. In case where sight is corrected with glasses, the strength of glasses of each eye should be mentioned Station: Date: Signature (Name) Degree & Registration No. Name of State Medical Council 7

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