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VYDEHI INSTITUTE OF MEDICAL SCIENCES
& RESEARCH CENTRE
#82, EPIP AREA, WHITEFIELD, BANGALORE – 560 066

 
Application Form for Selection to Post Graduate Courses In MD/ MS /M.Sc / Diploma Courses Under
Management Seats (N.R.I/I.P) for the Academic Year 20..…. – 20….

1. Name of the applicant
2 Father's Name
3 Spouse/ Husband Name
4 Full Postal Address
5 Address line1
6 Address line2
7 City
8 State
9 Pin Code
10 Phone no with STD code -
11 Mobile No
12 Email ID
13 Date of birth
14 Gender Male Female
15 Nationality
16 Name of college from where MBBS passed
17 Month / Year of passing
18 Is the MBBS course and college Recognized by Medical council of India Yes NO
19 Name of University
20 Type of University Indian Foreign
21 Permanent/ Provisional Medical Registration No
22 Name of State/ Central Council where registered
23 Date of completion of Internship
(Should complete internship before 30/4/2009)

Please enter the Marks/ Grade Scored in Qualifying

S. No Phase/ year Maximum Marks Marks obtained % No of Attempts Grade
1 First Year

2 Second Year
3 Third Year
4 Fourth Year
  Total

24 Category SC ST OBC
25 Religion
26 Caste
27 Mother’s Tongue
28 Order of Preference
Subject selected for Admission to Post
graduate course
M.D/ M.S/ DIPLOMA COURSES
26 Order of Preference
29 DD Amount
30 DD Number
31 DD Date (Format-dd/mm/yyyy)
32 DD Bank Drawn
33 Enter Remarks if any


DECLARATION BY THE CANDIDATE


1. I, Mr. / Ms. ……………………………..hereby affirm that the information furnished by me in this application and the enclosures is true. I know that if the information furnished by me is untrue, my seat will be forfeited.
2. I will not indulge in any form of ragging. I know it is a criminal offence and if found guilty, I will be
summarily dismissed. I undertake to make good the loss caused to the college/staff/student or any other person caused by any illegal act of mine.
3. I am liable to pay the balance of fees calculated for the entire course, in case I discontinue the course or I am expelled from the college for any reason.
4. I shall abide by all the rules and regulations of the college that may be framed from time to time.
5. In all matters regarding my admission to PG course, the decision of the college is final and binding on me.
Place: ……………………
Date:……………………. Signature of the applicant

DECLARATION BY PARENT OR GUARDIAN


1. I Mr./ Ms…………………………………………………..hereby affirm that the information furnished in my
Son’s / Daughter’s / Ward’s application and in the enclosures is true, I know that if the information
furnished by my Son/ Daughter / Ward is found to be untrue, my Son’s/ Daughter’s / Ward’s seat will be forfeited.
2. I know ragging is a criminal offence and shall take steps to prevent my Son/Daughter/Ward from indulging in it. I also know that if he / she is found guilty to the offence, he / she will be summarily dismissed from the college. I undertake to make good the loss caused to the college / staff/ student or any other person caused by any illegal act of my Son/Daughter/Ward.
3. I am liable for payment of the balance of fees calculated for the entire course, in case my Son /
Daughter/Ward discontinues the course or is expelled from the college for any reason.
4. I am also aware that once the candidate is admitted to the course, no refund of fees either in full or part there of will be made, for any reason.
Place: ……………………
Date:……………………. Signature of the Parent / Guardian

(Declaration to be signed by the Guardian, only in case of both father & mother of the candidate or not alive)


ANNEXURE I
LIST OF ENCLOSURES TO ACCOMPANY THE APPLICATION FORM
(Please tick the certificates attached and the checklist to be sent along with the application)

1 Processing fee of Rs.2.000/- only by way of DD favoring Vydehi Institute of Medical Sciences and Research Centre, payable at Bangalore along with the documents listed below.
(THREE PHOTOSTAT COPIES OF THE FOLLOWING DOCUMENTS)
2 Proof of Date of Birth (10th Marks Card/ SSLC Certificates).
3 All Marks cards of MBBS course from first to final year.
4 Attempt certificate.
5 Internship completion certificate (if not completed, provisional completion letter from Principal)
6 Provisional / Permanent Registration of the Medical council.
7 MBBS Degree Certificate.
8 Six recent passport-size color photographs with name and date.
9 Conduct/ Character certificate issued by the college last studied
10 Migration Certificate.
11 MCI – recognition certificate of the college from where student has completed the course.
12 Foreign Nationals seeking admission should obtain eligibility certificate issued by Rajiv Gandhi University of Health Sciences, Bangalore.

A. GUIDELINES TO FILL THE ONLINE APPLICATION FORM


1. Name of Candidate: Fill the name in BLOCK LETTERS, as per 10th/MBBS degree certificate
2. Father’s Name: Father’s Name should correspond to the form and spelling in the 10th standard
Marks Card.
3. Spouse’s /Husband’s Name: If married Spouse’s /Husband’s name in full should be filled.
4. Full Postal Address: Enter Full Postal Address with pincode for future correspondences
5. City/State Enter Name of the City & State where residing
6. Pincode: Enter pincode
7. Email ID: Enter Valid Email ID
8. Phone: Enter phone Number with STD code
9. Mobile: Enter Mobile Number
10. Gender: Select form the drop down list Female /Male
11. Date of Birth: The Date of Birth should correspond to the entry in the 10th standard Marks Card.
Ex: if the Date of Birth is 15th January 1965 it should be filled in the format 15/01/1965 only
12. Nationality: Select from the drop down list Indian / other
13. Name of College where MBBS passed: Select college in which you have studied MBBS from the
drop down list .If the college is not listed, select ‘Others’ from the drop down list and then enter the
college name in the field provided.
14. Month / Year of passing : Month / Year of passing from the drop down list
15. Is the MBBS course and college Recognized by Medical council of India Select Yes/No from
drop down List
16. Name of University: Select University in which you have studied MBBS from the drop down list. If
the university is not listed, select ‘Others’ from the drop down list and then enter the university name in the field provided.
17. Type of University : Select from the drop down list Indian / Foreign
18. Permanent / Provisional Medical Registration Number: Enter Permanent /Provisional
Registration Number, if you have already completed the course (Not applicable to candidates who
are still undergoing internship training)
19. Name of State /Central Council Where registered: Enter Name of the State/Central Council
where registered.
20. Date of completion of Internship: Enter the date of completion of compulsory rotatory internship. If you have not yet completed the compulsory rotatory internship as on the date of filling the application, mention the date on which you are likely to complete the internship supported by a certificate issued by the Principal/Dean of your college to the effect.
21. Please enter the Marks/ Grade Scored in Qualifying: Accordingly enter Marks or Grade awarded
to you in each year.
22. Category: Select from the drop down list the category you belong to
The candidates claiming reservation under SC, ST, Category –I, IIA, IIB, IIIA and IIIB should furnish
latest Income and Caste certificates issued by the Tahasildar in the forms valid as on the last date
for submission of application. If the certificates are not furnished along with the print out of filled
application,
23. Religion: Enter Religion you belong to
24. Caste:Enter Caste you belong to
25. Mother’s Tongue : Enter Mother Tongue / Language
26. Order of Preference : Select subject for admission to Post Graduate course
27. DD Amount: Enter fee payable as given in the brochure
28. DD Number: Enter 6 digits DD Number
29. DD Date: Enter DD Amount in dd/mm/yyyy format only
30. DD Bank Drawn: Enter DD drawn bank
31. Enter Remarks if any
After filling the online application form press Submit button, if you are sure that all the data entered by you is correct. An Application Number will get generated. Please record it for your future usage. Take the printout of the filled-in application and paste the recent passport size photograph in the space provided. The print out of the filled-in application duly signed by the candidate to be sent to college along with the required documents.

B. HOW TO SUBMIT:


I) IN PERSON:
Printout of Application form filled online, along with attested copies of all required certificates may be submitted for registration, in person, The Director Vydehi Institute of Medical Sciences and Research Centre, #82, EPIP Area, Whitefield, Bangalore-560 066”

II) BY POST:
Print out of application filled online, along with attested copies of all required certificates may be sent by post for registration to “The Director Vydehi Institute of Medical Sciences and Research Centre, #82, EPIP Area, Whitefield, Bangalore-560 066” Candidates should super scribe on the cover as “Application for PG Admission”.

C. CERTIFICATES TO BE ENCLOSED:
The attested copies of the following certificates are to be attached along with the application form. The Checklist given in Annexure – I should be used to tick the certificates attached and the checklist be sent along with the application.

D. CONTACT DETAILS
Mrs. D. A Kalpaja
Director
Vydehi Institute of Medical Sciences and Research Centre
#82, EPIP Area,
Whitefield, Bangalore-560 066
Tel: 080-284133382/3/4/5
Fax: 080-28412956
Email:info@vims.ac.in
Website:www.vims.ac.in