GOVERNMENT OF WEST BENGAL

DEPARTMENT OF HEALTH &FAMILY WELFARE

SWASTHYA BHAWAN, BLOCK-GN, SECTOR-V,
KOLKATA-700091.
Verification Formfor Admission to the 1
st
Year MBBS / BDS Course in the medical
/ Dental Colleges in West Bengal for the year to
All columns should be filled in. None should be left blank.
ROLL NO: APPLICATION NO:..
OVERALL STATE RANK:
(As mentioned in the WBJEEM Overall Rank 2014)
Admitted in (For Official Use)

1. Name of the Applicant :

(In BLOCK LETTERS)
2. (a) Name of the Father
..
(b) Name of the Mother
.
(c) Name of Guardian
:(If
not Father, then the reason thereof)
3. Address of the Applicant :
(a) Present Address
:
.
(Where communication is to be made)
(b) Phone No. Email..
Permanent Address
:.
(b) Phone No. Email..
4. If belongs to Scheduled Castes / Scheduled Tribes/Other Backward Classes (A / B)
5. Write (YES /NO)
N.B. If Yes , an attested copy of SC/ST/OBC A/OBC B certificate from the appropriate authority
mentioning the Sub-Caste/ tribe must be enclosed. Otherwise the application will not be considered.
(Attach attested copy of appropriate documents)
6. If belongs to Physically Handicapped. Write (YES /NO):.
N.B. If Yes, an attested copy of PH certificate from the appropriate authority must be enclosed.
Otherwise the application will not be considered. (Attach attested copy of appropriate documents)
7. (a) Date and Year of Birth

(b) Age as on 31
st
December of the Year of Admission (2014)

According to English Calendar as per Madhyamik/ Equivalent Examination Certificate/ documents like
Admit Card etc. (Attach attested copy of appropriate document).
8. Whether he /she likes to be considered against 8(a) or 8(b)-Mention either a or b
(a) Candidates residing uninterruptedly in the State of West Bengal for a minimum period of ten years
prior to the date of making application for admission to MBBS/ BDS Course
.
OR
(b) Candidates who or whose parents are permanent / resident of West Bengal having their
permanent Address in the State of West Bengal.
9. Higher Secondary (10+2) or Equivalent Examination as per advertisement

(Attach attested copy of appropriate document).
10. Declaration by the Applicant and Father / Guardian :
We jointly declare that all foregoing statements are true to the best of our belief and knowledge. Any
Statement, made in the Application, if found incorrect or incomplete, on Scrutiny, will render the Application
liable to rejection and admission if granted on the basis of such incorrect statement may be cancelled
without any intimation to any of us.
We further declare that we have gone through the terms and conditions of Advertisement and Instructions
and agree to abide by the conditions laid down therein.
We also agree that the decision of the Central Selection Committee (Medical) with regard to Selection,
Allotment and Admission to any of the colleges will be acceptable to and binding on us.
We are aware that the following Original Documents are to be produced during Counselling (If any name is
in the Merit List):-
1. Class X Admit Card / Mark Sheet (Documenting the Date of birth).
2. Class ( 10+2) Mark Sheet & Certificate.
3. Examination Results WBJEEM 2014(rank card).
4. Allotment letter obtained from www.wbmcc.nic.in
5. SC/ ST/ OBC A/OBC B/ PH Category Certificate (Wherever Applicable).
6. Domicile Certificate- Candidates copy in the prescribed Application Form available in information
brochure of WBJEEM 2014 must be produced.
7. Medical Certificate.
8. Voter ID card of any of the parents or candidate (as applicable)
We are also aware that Original 10+2 Examination Certificate and Original Mark sheet are to be
deposited at the time of Admission without fail till the completion of the Course. In case of any
Discontinuation from the Course offered or Resignation from the Course after Reconciling of this State, all
Original Documents shall be returned only on payment of a penalty charge of Rs. 1,00,000/- (Rupees One
Lakh) only asper G.O. No. HF/O/MERT/1542/Admin/ME/STM-28-10/2(10) dt 25/10/10.
All Originals will be Verified at the time of Counselling
...
(Signature of Father/ Guardian) (Signature of Applicant)
Place. Place.
Date.. Date..