ADMISSION FORM-2011

Roll No. ................................. (Leave Blank)

FOR MBBS/BDS IN MEDICAL/DENTAL COLLEGES OF RAJASTHAN

(No column should be left blank. If not applicable, it should be marked NA. Use CAPITAL LETTERS only)

First Name 1. Name of the candidate (IN BLOCK LETTERS) 2. Fathers Name 3. Mothers Name 4. *Guardians Name 5. Relationship

Middle Name

Last Name

*Any person, other than the parents of the candidate, can become guardian only if the parents are not alive or are insane.

Affix your recent Coloured photograph duly signed by the candidate and attested by a Competent officer as explained in Information Booklet

6. Date of Birth
(DD) (MM) (YYYY)

7. Age on 31st December, 2011

(Years) (Months) (Days)

8. Sex
Male/Female

9. Nationality ......................... 10. Religion............................... 11. State............................ 12. Place of Birth......................................... 13. Rural/Urban .............................................

14. Occupation of Father/Guardian............................... Annual Income Rs. .......................... (Govt./Pvt.) If in Govt. Service mention details of the post.................................................................... 15. (i) Address for Correspondence (ii) Candidates Permanent Address

PIN Telephone No. with STD Code Mobile No. 16. Category (General Boy/SC Boy/ ST Boy/ Scheduled Area Tribal Boy/OBC Boy/ SBC Boy/General Girl/SC Girl/ST Girl/Scheduled Area Tribal Girl/OBC Girl/ /SBC Girl) 17. Additional Category, if any (PH/DP/PM) Telephone No. with STD Code Mobile No.

PIN

(1)

18.

Details of Educational Institutions where the candidate studied during last 10 years.
Years Name of Institution Class in which Studied Name of City/Village and State

2010-2011 2009-2010 2008-2009 2007-2008 2006-2007 2005-2006 2004-2005 2003-2004 2002-2003 2001-2002

DECLARATION BY THE CANDIDATE

1. I have read the rules and regulations of RPMT-2011. Regarding admission to the Medical/Dental Colleges, I find myself eligible for the same. I realise that if the Admission Board decides that I am not eligible, I shall abide by its decisions. 1 do solemnly affirm that the statement and information furnished by me as above and also in the enclosures submitted are true. I realise that, if any information furnished therein is found untrue in material particulars, I shall be liable to criminal prosecution as well as forego my admission and to be removed from the College, if already admitted. I shall abide by the decision of the Admission Board. I also undertake to pay the College, Hostel and other dues regularly. I hereby agree, if admitted, to abide by the rules and regulations at present in force and those that may here after be made for the administration of the college and I undertake that so long as I am a student of the College, I will do nothing either inside or outside the College that will interfere with its orderly working and discipline. I also declare that : (a) I have not been convicted of any criminal offence nor have I been released on bail in connection with a criminal case. (b) No case of criminal offence or moral turpitude is pending against me in any Court of Law. (c) No complaint or F.I.R. has been lodged against me by the University/Principal of a Constituent College/School. (d) I have not resorted to any act of indiscipline in past year(s). (e) I have not been debarred from appearing in RPMT earlier. I understand that if all the necessary documents are not appended with the form, the form is liable to be rejected. Affix Left Thumb Impression Affix Right Thumb Impression Signature of the Candidate

2.

3. 4.

5.

6. 7.

Verified by : Date : ..................2011

(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 NO. 1 PARENTS/GUARDIANS CERTIFICATE

1. I, .......................................................................................... solemnly affirm income is Rs. .............................. OR #I.................................. solemnly affirm that Shri/Km. ................................... is the son/daughter of Shri........................................................... and, I am the guardian of Shri/Kumari............................................. as his/her parents have died/become insane. He/She is my.................................... (state relationship) 2. I hereby solemnly affirm that the statement and information furnished in my sons/ daughters/wards application as also in the enclosed enclosures thereto are true. I realize that if any information furnished therein is found to be untrue in material particulars, my ward is liable to criminal prosecution and if admitted, to be removed from the institution. I undertake to be responsible for his/her conduct and for maintenance of discipline and shall pay regularly all his/her expenses during his/her stay at the institution. that I am

the natural father/mother* of Shri/Kum. ...........................................and my monthly

3.

Date : .................2011 Place : .........................

Signature of Father/Mother/Guardian

*If natural father is not alive. #If natural parents are not alive or are declared insane.

CERTIFICATE NO. 2 CERTIFICATE OF PRINCIPAL OF THE SCHOOL/COLLEGE LAST ATTENDED

I certify that Shri/Kumari....................................... Son/Daughter of Sh. ................................ or

of my School/College has passed Exam in all the subjects of Senior Secondary, (10+2) Equivalent examination with particulars given in Academic Record Table as below : Academic Record Table
Roll No. Year of Passing Board Division Physics Chemistry Biology English

Max. Marks Max. Marks Max. Marks Max. Marks Mark Obtained Mark Obtained Mark Obtained Mark O Obtain
ed

Date : ..................2011 Place : .........................

Signature of the Head Master/ Principal with Office Seal (3)

CERTIFICATE NO. 3

CERTIFICATE OF ELIGIBILITY
NOTE : Any one out of following eleven Certificates (I-XI) is necessary, failing which the form shall be rejected.

ELIGIBILITY CERTIFICATE UNDER RULES 3 (C) (i)

I Certify that Shri/Kumari ................................... Son/Daughter of..................................... has studied for the last three years of the qualifying examination (X-XI & XII) continuously as a regular candidate in recognised Institution in Rajasthan and is an Indian National.

Date................ 2011 Place ..............

Signature of the Head Master/Principal/ Head of Institution last attended With Official Seal

II

CERTIFICATE UNDER RULES 3(C) (ii)

I certify that Shri/Kumari .................................................................. is the natural Son/ Daughter (not adopted) of Shri/Shrimati......................................................... and his/her Father/Mother has been continuously residing in Rajasthan for a period of 10 years and that he/she has studied for at least 5 years in this period in recognised educational institutions in Rajasthan. The details of period of study in recognized educational institutions are given in Proforma on Page 2.

Date ..............2011 Place ....................

Signature of the District Magistrate/ Addl. District Magistrate/ Sub. Divisional Magistrate Executive Magistrate

III CERTIFICATE UNDER RULES 3 (C) (iii) BONAFIDE RESIDENT CERTIFICATE

The candidate should submit attested copy of his/her Bonafide Resident Certificate issued by the Competent Authority of Government of Rajasthan. Name of Competent Authority Official Address Date of Issue of certificate State where studying ........................................ ........................................ ........................................ ........................................ (4)

IV

CERTIFICATE UNDER RULES 3(C) (iv) a

I certify that Shri/Smt ........................................................................... Father/Mother of Shri/Kumari............................is serving/retired (i) employee of Government of Rajasthan or (ii) is an Officer of All India Service born on the State Cadre of Rajasthan. He has served for m or e t h a n 3 years with t h e St at e G o v e r n m e n t as............................ for t h e period from.....................to........................... in the Department of............................. (designation). Date................ 2011 Place .............. Signature of the Employer/ Head of the Department Designation and Seal

CERTIFICATE UNDER RULES 3(C) (iv) b

Certify that Shri/Shrimati ........................................................................ Father/Mother of Shri/Kumari ........................................................... is a serving/retired, permanent employee of Government Undertaking/corporation/Improvement Trust/Municipal Board/Council/ Panchayat Samiti/Co-operative Bodies, duty constituted by the Government of Rajasthan 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....................... since ................... (designation)......................................... (Body/Dept.) Date................ 2011 Place .............. Signature of the Employer/ Head of the Department Designation and Seal

VI
Certify that

CERTIFICATE UNDER RULES 3(C) (iv) c

Shri/Shrimati........................................................................ . is a serving/retired, permanent Father/Mother employee of

of Shri/Kumari..................................... Education, Rajasthan and has put submission of application in the as.................................in the

University (Name) ......................................................... in Rajasthan or Board of Secondary in atleast three years service on the last date for year of examination. He/she is in service

.......................................... since ..................... (designation) ......................... (Body/Dept.) Date................ 2011 Place .............. Signature of the Employer/ Head of the Department Designation and Seal

VII

CERTIFICATE UNDER RULES 3 (C) (v) FOR DEFENCE PERSONNEL OF RAJASTHAN ORIGIN

I certify that Shri/Kumari........................................................is a natural Son/Daughter of Shri/Shrimati.............................................. and his/her Father/Mother is serving/retired permanent employee in Indian Defence Service and he/she is of Rajasthan origin and the home town as given by him/her at the time of his/her entry into service is................................. town............................ Dist.......................... State.................................... He/she comes under priority* .................. meant for the Wards of Defence Personnel. (*See Priorities I to IV as mentioned in Information Booklet). Date................ 2011 Place .............. (5) Signature of the Employer (with Official Seal)

VIII

CERTIFICATE REGARDING DEFENCE PERSONNEL NOT OF RAJASTHAN ORIGIN BUT SERVING IN RAJASTHAN

I certify that Shri/Kumari....................................................... is a natural Son/Daughter of Shri/Shrimati .............................and his/her Father/Mother is serving employee 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 continuing in Rajasthan at present. He/She comes under Priority ....................................... meant for Defence Personnel. Date................ 2011 Place .............. Signature of the Employer (with Official Seal)

IX

CERTIFICATE UNDER RULE 3 (C) (vi) FOR PARA MILITARY PERSONNEL OF RAJASTHAN ORIGIN

I certify that Shri/Kumari .................................................. is a natural Son/Daughter of Shri/Shrimati ............................................. and his/her Father/Mother is serving/retired permanent employee in Para Military Force and he/she is of Rajasthan origin and the home town as given by him/her at the time of his/her entry into service is ............................. town ...................................... Dist................................ state............................ Date................ 2011 Place .............. Signature of the Employer (with Official Seal)

CERTIFICATE REGARDING PARA MILITARY PERSONNEL NOT OF RAJASTHAN ORIGIN BUT SERVING IN RAJASTHAN

I certify that Shri/Kumari....................................................... is a natural Son/Daughter of Shri/Shrimati....................................................................... and his/her Father/Mother is serving employee of Para last......................... years Military Forces. He and is has been in on the service for the post the of working

..................................since..............................in this unit and is posted in Rajasthan from ....................... and is continuing in Rajasthan at present. Date................ 2011 Place .............. Signature of the Employer (with Official Seal)

XI

CERTIFICATE UNDER RULE 3 (C) (vii) FOR SON/DAUGHTER OF A JUDGE OF RAJASTHAN HIGH COURT

I certify that Shri/Kumari........................................................ is a natural Son/Daughter of Shri/Shrimati ............................................................................... A Judge of Rajasthan High Court subject to that he/she submits an undertaking/affidavit stating that such benefit is not being claimed or availed by him/her in any other State. Date................ 2011 Place .............. (6) Signature of the Employer Rajasthan High Court (with Official Seal)

FOR OFFICE USE ONLY

Total Marks Obtained in RPMT-2011

Name of the College allotted ............................................................................. (1st Counselling)

Signature of Chairman/Convener RPMT-2011 Counselling UG Admission Board.

Change (if opted)/fresh allotment ..................................................................... (2nd Counselling)

Signature of Chairman/Convener RPMT-2011 Counselling UG Admission Board.

(7)

DESCRIPTION OF ESSENTIAL DOCUMENTS

(TO BE FILLED BY THE CANDIDATE)
1. List of documents : [Mark tick (3) if photostat/true copy (duly attested as per Information Booklet) is enclosed and Cross (X) if not enclosed.
S.No. Document Enclosed (3) Not enclosed (X)

1. 2. 3. 4. 5.

Marksheet of passing the Secondary 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/ Schedule Tribal Area/OBC only) issued by the competent authority. Certificate of Physically Handicapped (for PH only) clearly mentioning the locomotor disability of lower limbs between 50% to 70% issued by the competent Medical Board as required in Information 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 must ensure that his/her priority (I to IV as mentioned in Information Booklet) is clearly mentioned in the Certificate Printed in the Form A. The candidate is also required to enclose photocopy of relevant certificate, if applying under Priority II or III. Two coloured photographs with name of candidate and his/her form number on the back of the photographs.

4.

Note : 1. Do not enclose any original certificate with Application Form. 2. All original certificates have to be produced before U. G. Admission Board at the time of Interview (Counseling)

FOR OFFICE USE ONLY

10th Marksheet 12th Marksheet Date of Birth Certificate Reservation category Certificate PH Certificate Eligibility Certificate DP Priority

Eligibility requirements fulfilled

YES/NO

Remarks (If any) .................................................................................................................

Signature of Form Scrutinser Office of Convener RPMT-2011 Rajasthan University of Health Sciences , Jaipur

(8)

ADMISSION FORM RPMT-2011

1. 2. 3. 4.

Roll No Category. Over all Merit No.. Name of Candidate

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.

10th Marks % (Total % All the Subjects).

7.

10+2 Marks % (% of only Phy., Chem. & Bio.)..

8.

R.P.M.T. Marks .

Signature of Candidate

(9)