MAHARAJA KRISHNAKUMARSINHJI BHAVNAGAR UNIVERSITY BHAVNAGAR (GUJARAT-INDIA)

Transcription

1 MAHARAJA KRISHNAKUMARSINHJI BHAVNAGAR UNIVERSITY BHAVNAGAR (GUJARAT-INDIA) FACULTY OF MEDICINE APPLICATION FORM FOR ADMISSION TO POST- GRADUATE MEDICAL DEGREE AND DIPLOMA COURSES YEAR (Last Date of Submission of Filled Form 20/03/2014) AT THE GOVT. MEDICAL COLLEGE BHAVNAGAR AFFILIATED TO MAHARAJA KRISHNAKUMARSINHJI, BHAVNAGAR UNIVERSITY, BHAVNAGAR (GUJARAT, INDIA ). WEBSITE : ID: dean.health.bhavnagar@gmail.com Phone No: , , Fax : No Note : Candidates have to submit separate form for each category. (` 500/- for General/SEBC/MO categories, free for SC/ST categories) Forms will be free online (download form in A4 size only)

2 Govt. Medical College, Bhavnagar (Gujarat) Undertaking by the applicant for P.G. course (MS/MD/ Diploma) 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 later on found to be false or incorrect or 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 have 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 seats are subjected to approval from Medical Council Of India. In case of any cancelation by Medical Council of India, My admission is liable to be cancelled, for which Institute or University will not be held responsible. 4) Post graduate admission process will be as per the directive of Honorable Court of MCI, DGHS, Government of Gujarat. Date:... Signature of Applicant Place:... Name :... Address: Mobile:... E mail id:... In presence of Witness Name :... Sign:...Date:... Cell no :... Address...

3 MAHARAJA KRISHNAKUMARSINHJI BHAVNAGAR UNIVERSITY BHAVNAGAR (GUJARAT - INDIA) Application form for admission to POST-GRADUATE DEGREE AND DIPLOMA IN MEDICAL COURSES TO BE FILLED IN BY THE APPLICANT 1. Full name of the Applicant : (Fill in one letter in each square) (a) Name Affix Passport size Recent Photograph (b) Father s / Husband s Name (c) Surname 2. Gender : (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.. id:... PHONE NO Mobile:... Permanent (if other than above) address:...pin.. PHONE NO Nationality :.

4 7. Academic year for which applied : 8. Information regarding STATUS : 2014 (Enter the code No. in the square) (1) Graduate from Maharaja Krishnakumarsinhji, Bhavnagar University, Bhavnagar, under rule (2) Graduate from Maharaja Krishnakumarsinhji, Bhavnagar University, under rule (3) + Graduate from other University of Gujarat State under rule (4) * Graduate from other University of Gujarat State, who has not joined P.G. Courses anywhere.(degree/diploma), under rule (5) * Graduate from University outside Gujarat State Category for which applied (Enter the code No. in the square ) 1) Open Merit 2) Scheduled Caste (SC) 3) Scheduled Tribe ( ST) 4) Socially and Economically Backward Community (SEBC) (Not included in creamy layer) 5) Physically handicapped (PH) 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 Maharaja Krishnakumarsinhji, Bhavnagar University, Bhavnagar. (+) The Medical College, from which candidate has graduated must be recognized by Medical Council of India. Candidates are supposed to attach certificate from concerned institute about M.C.I. Recognition status. ** Medical Officers must submit NOC from Department of Health and Family Welfare Government of Gujarat. (Director of Health)

5 (*) 10. Detail of marks obtained at various examination : Examination University Date of starting Exam III M.B.B.S. Part II III M.B.B.S. Part I Dt. Mth Yr Dt. Date of result (Date of Mark sheet) Total aggregate marks obtained in Theory & Practical s Attempts including Drops Mth Yr Marks obtained Total Theory Out of Pract. Out of out of Total Total II M.B.B.S Total I M.B.B.S 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)

6 For 11 and 12 (*) Non appearance in the University examination, when due, will be considered as failure & attempt will be considered accordingly. (*)11. Failures and drops Exam Date Failure or Drop 1).. 2).. 3).. 4).. 5).. 6).. 7).. 8).. 9).. 10).. 11).. 12).. 13) Date of admission in I M.B.B.S. Date Month Year 13. 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 Date of passing final M.B.B.S. examination 15. Internship completed on 16. Date of award of degree (Convocation) Date Month Year 17. Have you applied for P.G. course before anywhere? Yes : 1 No : Medical council Registration no. :

7 If yes, give the detail in the following Performa: University Details Maharaja Krishnakumarsinhji, Bhavnagar University, Bhavnagar. (Other specify) a. Date of Application b. Application Reg.No. c. Selected and joined d. If selected and joined 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 Yes/No Yes/No Yes/No 18. Detail of present Employment : 19. Detail of past Employment : (a) Designation.. (b) Place of working. (c) Date of joined. (NOC from present employer to be submitted) Designation (i) (ii) Period for which held From..to. Total period Year & Month Signature of student... Place:... Date :... Name of student:... Cell no.... ID...

8 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 (d) Mark sheets of all attempt of I M.B.B.S. Examination (e) Attempt Certificate of I,II,III (Part 1 and 2)M.B.B.S. (f) Caste Certificate ( For category 2,3 & 4only) (a). (b). (c) (d) (a) (b). (c) (d)... (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 (g) Provisional Eligibility Certificate ( Essential for candidate from university other than Bhavnagar University) (h) Internship completion certificate. (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 (10 th ) 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