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Admissio N Form-2011: For Mbbs/Bds in Medical/Dental Colleges of Rajasthan
Admissio N Form-2011: For Mbbs/Bds in Medical/Dental Colleges of Rajasthan
ADMISSIO N FORM-2011
FOR MBBS/BDS IN MEDICAL/DENTAL
(Leave Blank)
COLLEGES OF RAJASTHAN
Middle Name Last Name
(No colum n shoul d be lef t blank . If no t applicable , it shoul d be m arke d NA. Use CAPITAL LETTER S only)
First Name 1. Nam e of the candidat e (IN BLOCK LETTERS) 2. Father s Name 3. Mother s Name 4. *Guardian s Name 5. Relationship
*Any person, other than the parents of the candidate, only if the parents are not alive or are insane. can becom e guardian
Affix your recen t Coloured photograph duly signed by the candidate and attested by a Competent officer as explained in Information Booklet
6. Date of Birt h
7. Age on 31 st December,
2011
8. Sex
(DD)
(MM)
(YYYY)
(Years)
(Months )
(Days)
Male/Female
9. Nationalit y ........................
If in Govt. Servic e mentio n detail s of the post.................................................................... 15. (i) Addres s for Correspondenc e (ii) Candidate s Permanen t Address
PIN Telephon e No. with STD Code Telephon e No. with STD Code
PIN
Mobile No.
Mobile No.
16. Categor y (Genera l Boy/S C Boy/ ST Boy/ Scheduled Area Tribal Boy/OBC Boy/ SBC Boy /Genera l Girl/S C Girl/S T Girl/Scheduled Area Triba l Girl/OB C Girl/ /SBC Girl) 17. Additiona l Category , if any (PH/DP/PM) (1)
18.
Detail s of Educationa l Institution s wher e the candidat e studie d durin g las t 10 years.
Years Name of Institution Class in which Studie d Nam of City/Village e and S tate
2010 -201 1 2009-2010 2008-2009 2007-2008 2006-2007 2005-2006 2004-2005 2003-2004 2002-2003 2001-2002
2.
3. 4.
5.
6. 7.
(Signature & Seal) Signature & Thumb Impression should be verified and marked in presence of Principal of School/College last attended/ Gazetted Officer/Executive Magistrate. Note : Candidate must sign the form and affix left & right Thumb Impressions failing with the application form will be rejected.
Place : ..........................
(2)
CERTIFICATE PARENTS/GUARDIAN
1. th e natura l father/mother
NO. 1 S CERTIFICATE
. solemnl y affirm tha t I am d my monthly
* of Shri/Kum . ...........................................an
. is the
. as his/he r parent s have died/becom e insane. in my sons/ o ar e true . I e in material removed from and
I hereb y solemnl y affirm tha t the statemen t an d informatio n furnishe d daughters/ward s applicatio n as also in the enclose d enclosure s theret realiz e tha t if any informatio n furnishe d therei n is foun d to be untru particulars, my ward is liable to criminal prosecution and if admitted, to be the institution.
3.
I undertake to be responsible for his/her conduct and for maintenance of discipline shal l pa y regularl y all his/he r expense s durin g his/he r stay at the institution. Signatur e of Father/M other/G uardian
*If natura l fathe r is not alive. #If natura l parent s are not alive or are declare d insane.
CERTIFICATE CERTIFICATE
of my School/College
Exam in all the subject s of Senio r Secondary , (10+2) Record Table as below :
Biology
Marks Max. Mark Obtained
Chem istry
Marks Max. Mark Obtained
English
Marks Max. Mark O Obtaine d
Principa l
CERTIFICATE
NO. 3
CERTIFICAT E OF ELIGIBILITY
NOTE : Any one out of following eleven the form shall be rejected. Certificates (I-XI) is necessary, failing w hich
ELIGIBILITY CERTIFICATE
i ..................................
Signatur e of the Hea d M aster/Principal/ Hea d of Institutio n las t attended With Official Seal
II
I certif y tha t Shri/Kumar Father/M other he/she Proforma
CERTIFICATE
Daughte r (no t adopted ) of Shri/Shrimati........................................................ has been continuously has studied on Page 2. for at least 5 years in this period in recognised educational
Rajasthan . The detail s of perio d of stud y in recognize d educationa l institution s are given in
Signatur e of the Distric t M agistrate/ Addl. Distric t M agistrate/ Sub . Divisiona l Magistrate Executiv e Magistrate
The candidate should subm it by th C petent e om A uthority Nam e of Competen t Authority Officia l Address Dat e of Issu e of certificate Stat e wher e studying
attested copy of h er Bonafide is/h of G overnm ent of R ajasthan. ........................................ ........................................ ........................................ ........................................
Resident
Certificate
issued
(4)
IV
CERTIFICATE
I certif y tha t Shri/Sm t .......................................................................... . Father/M othe r of Shri/Kumari............................i s serving/retire d (i) employe e of Governmen t of Rajastha n or (ii) is an Officer of All India Service born on the State Cadre of Rajasthan. He has served for mor e tha n 3 year s with th e Stat e Governmen t as........................... . for th e perio d from.....................to.......................... . in the Departmen t of............................ . (designation). Date............... . 2011 Place ............. . Signatur e of the Employer/ Hea d of the Department Designatio n and Seal
CERTIFICATE
Certif y tha t Shri/Shrim at i ....................................................................... . Father/M othe r of Shri/Kumar i .......................................................... . is a serving/retired , permanen t employee of Governmen t Undertaking/corporation/Improvemen t Trust/Municipa l Board/Council/ Panchaya t Samiti/Co-operativ e Bodies , dut y constitute d by the Governmen t of Rajastha n by an Act of Law who has put in atleast three years of service on the last date of submission of application in the year of admission. He/she is in service as...................... in the....................... sinc e .................. . (designation)........................................ . (Body/Dept.) Date............... . 2011 Place ............. . Signatur e of the Employer/ Hea d of the Department Designatio n and Seal
VI
CERTIFICATE
Certif y tha t Shri/Shrim ati........................................................................ . Father/M othe r of Shri/Kumari.................................... . is a serving/retired , permanen t employe e of University (Name ) ........................................................ . in Rajastha n or Boar d of Secondar y Education, Rajastha n an d ha s pu t in atleas t thre e year s servic e on the las t dat e for submissio n of applicatio n in the year of examination . H e/sh e is in servic e as.................................i n the ......................................... . sinc e .................... . (designation ) ........................ . (Body/Dept.) Date............... . 2011 Place ............. . Signatur e of the Employer/ Hea d of the Department Designatio n and Seal
VII
CERTIFICATE UNDER RULES 3 (C) (v) FOR DEFENCE PERSONNEL OF RAJASTHAN ORIGIN
I certif y tha t Shri/Kumari........................................................i s a natura l Son/Daughte r of Shri/Shrim ati............................................. . an d his/he r Father/M othe r is serving/retired permanen t employe e in India n Defenc e Servic e an d he/sh e is of Rajastha n origi n an d the home town as given by him /her at the tim of his/her entry into service is................................. e town............................ D ist.......................... State.................................... H e/she com es under priority * ................. . m ean t for th e Ward s of Defenc e Personnel. (*See Prioritie s I to IV as mentione d in Informatio n Booklet). Date............... . 2011 Plac e ............. . (5) Signatur e of the Employer (with Official Seal)
VIII
CERTIFICATE REGARDING DEFENCE PERSONNEL NOT OF RAJASTHAN ORIGIN BUT SERVING IN RAJASTHAN
I certif y tha t Shri/Kum ari...................................................... . is a natura l Son/Daughte r of Shri/Shrim at i .............................an d his/he r Father/M othe r is servin g employe e of Defence Service of India. He has been in the service for the last..................... years and is working on the post of .......................................... from .................. in this unit and is posted in Rajasthan since......................and is continuin g in Rajastha n at present . He/Sh e come s unde r Priority ...................................... . m ean t for Defenc e Personnel. Date............... . 2011 Plac e ............. . Signatur e of the Employer (with Official Seal)
IX
CERTIFICATE UNDER RULE 3 (C) (vi) FOR PARA MILITARY PERSONNEL OF RAJASTHAN ORIGIN
i ................................................. . is a natura l Son/Daughte r of i ............................................ . an d his/he r Father/M othe r is serving/retired town
perm anen t employe e in Par a Militar y Forc e and he/sh e is of Rajastha n origi n and the home town as given by him /her ..................................... Date............... . 2011 Plac e ............. . at the tim of his/her e . Dist............................... entry into service is ............................. . state............................ Signatur e of the Employer (with Official Seal)
CERTIFICATE REGARDING PARA MILITARY PERSONNEL NOT OF RAJASTHAN ORIGIN BUT SERVING IN RAJASTHAN
. is a natura l Son/Daughte . an d his/he r Father/M othe r of r is
serving employee of Para Military Forces. He has been in the service for the last......................... year s an d is workin g on the pos t of ..................................since..............................i unit and is posted in Rajasthan Date............... . 2011 Plac e ............. . from ....................... and is continuing in Rajasthan n this at present.
XI
CERTIFICATE UNDER RULE 3 (C) (vii) FOR SON/DAUGHTER OF A JUDGE OF RAJASTHAN HIGH COURT
. is a natura l Son/Daughte stating that such benefit r of is not i .............................................................................. to that he/she subm its an undertaking/affidavit in any other State. Signatur e of the Employer Rajastha n High Court (with Official Seal) (6) or availed by him /her . A Judg e of Rajastha n High
in RPMT-2011
(7)
as per Information
Enclosed (3) Not enclose d (X)
1. 2. 3. 4. 5.
Marksheet
School Exam.
Marksheet of passing the Senior Secondary School/10+2 or equivalent Exam. (if appeared-write appeared) Secondary School Exam. Certificate in support of Date of Birth (if it is not mentioned in the mark sheet of Secondary School exam.) Certificate in proof of desired reservation category (For SC/ST/ Schedul e Triba l Area/OB C only) issue d by the competen t authority. Certificat e of Physicall y Handicappe d (for PH only) clearl y mentioning the locomoto r disabilit y of lower limb s betwee n 50% to 70% issue d by the competen t Medica l Boar d as require d in Informatio n Booklet.
2. 3.
Certificate of eligibility under clause 3(C) printed in the Form A under the heading of Certificate No. 3 (Any one Certificate out of eleven must be filled in and signed by competent authority) The candidate applying under Defence Personnel of Rajasthan Origin m ust ensure that his/her priority (I to IV as mentioned in Information Booklet) is clearly mentioned in the Certificate Printed in the Form A. Th e candidat e is als o require d to enclos e photocop y of relevan t certificate , if applying under Priority II or III. Two coloure d photograph s with nam e of candidat e and his/he r form num r on the bac k of the be photographs. Board at the tim of e
4.
Note : 1. Do not enclose any original certificate w ith A pplication Form . 2. All original certificates have to be produced before U. G. A ission dm Interview (Counseling)
Eligibilit y requirement
s fulfille d
YES/NO
Signature of Form Scrutinser Office of Convener RPMT-2011 Rajasthan University of Health Sciences , Jaipur
(8)
1. 2. 3. 4.
Affix your recent Coloured Photograph duly signed by the candidate and attested by a competent officer as explained in Information booklet
5.
Fathers Name
6.
7.
8.
R.P.M.T. Marks .
Signature of Candidate
(9)