PGIMER 2015 Information Brochure - MD MS

8/11/2019 PGIMER 2015 Information Brochure - MD MS

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Roll No.

IMPORTANT INSTRUCTIONS:1. Please read the prospectus and the instruction given inprospectus carefully before filling this form. 2. Use blue or black ball pen for filling this form.3. Tick ( ) in the appropriate box against columns 1(a), 1(b) 5, 6, 11(a) and 12.

3. Full Name of applicant (In CAPITAL Letters and as per matriculation certificate) Please don't write Dr./Mr./Mrs./Ms. before names.

4. a) Father's/Husband's Name (In CAPITAL Letters)

b) Mother's Name (In CAPITAL Letters)

5. Gender

Male Female6. Nationality

Indian Others Date7. Date of Birth

Month Year

8. Details of MBBS examination passed

(a) Month & Year of Admission

MONTH YEAR

(b) Month & Year of passsing the examination

MONTH YEAR

c ) Total Marks in 1st+2nd+3rd+4th

Maximum Marks Marks obtainod Percentage

Th H T O Th H T O

10. (a). Date of starting Internship

Date Month Year Date Month Year

(b) Date / Expected date of complet ion of Internship (c) No. of days

11. from which MBBSName of College/University passed 14 (a). PHOTOGRAPH

POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH

(To be assigned by office)

Challan/Journal/INB Reference No ..............................................................................................................in favour of Director, PGI , Chandigarh

PastePassport Size

coloured Photographwith

Name and Date

DETAIL OF FEE:

1(a). Category

General ScheduleCasteOBCSchedule

TribeRural AreaServices

Person withDisability

Sponsored/Deputed

ForeignNational

1

Any deviation or discrepancy between actual appearance at the time of examination and facial appearance in the photograph pasted on theapplication will make the candidate liable for rejection.

2. Subject Choice: The Foreign National candidates may fill up three choices only.(Note : The Change of category at any stage will not be permitted, tick only in one box)

(a) Whether recognized by Medical Council of India ?

12. Have you already done or doing any PG Degree?

YES NO

14 (b). SIGNATURE OF THE CANDIDATE(Use Black Ball Pen Only)

................................................................................................................................................................................

I) II) III)

9. Medical Registration Detail:

a) Permanent/Provisional b) State

c) Date of Registration

D YD M M Y YY

For Office use only

APPLICATION/REF. NO ............................. ................. .................. .................. ................... ..........

APPLICATION FOR THE ADMISSION IN MD/MS COURSES FOR JANUARY-2015 SESSION

.

3rdGender

1(b). Category (if applicable)

YES NO

13. MOBILE NO.


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15. Address :

A) Permanent Home Address :

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

Contact No. of home with STD Code__________________________

Mobile No.: _____________________________________________

E-mail: _________________________________________________

B) Correspondance Address :

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

Contact No. with STD Code_________________________________

Mobile No.: _____________________________________________

E-mail: _________________________________________________

18. State/Union Territory to which you belong : ________________________________________________________________

19. Are you employed if yes, give the following details :

a) Date of Joining as regular service : ________________________________________________________________

b) Nature of job (Permanent/Contractual/Adhoc) : ________________________________________________________________

c) Name of the Institution/Hospital Govt./Semi Govt./ Pvt. : ________________________________________________________________

d) Designation ________________________________________________________________ :

: e) Pay Scale ________________________________________________________________

f) Name of employer ________________________________________________________________ :

20. Are you being sponsored/deputed by your employer? if sponsored, the application must be accompanied with sponsorship, deputation certificate in the form printed at Annexure '5 : ________________________________________________________________

21. Have you any contact person/guardian inChandigarh. If so, mention his/her address

Telephone No., If any. : ________________________________________________________________

16. Married or Unmarried :________________________________________________________________(If married, wife/husband name and occupation)

17. Nationality : ________________________________________________________________

*There is no need to fill the above certificate in case the Internship Certificate has already been issued by the Institute/Hospital/College (Attach attested copy)

2

INTERNSHIP CERTIFICATE

(To be submitted by the candldate whose Internship is complete or likely to be completed by 30th june/31st Dec for July & Jan session repectively.)

Certified that Dr. _____________________________________________has undergone/presently been undergoing 12 -months compulsory

Rotating Internship Training at ____________________________________________________________________college which started

on __________________and has completed or is likely to be completed on _______________________

Place :______________

Date :_______________ Signature & Seal of Dean/Registrar/Principal/Medical Superintendent of the Institution fromwhere the candidate or is undergoing internship.


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DECLARATION BY CANDIDATE

I hereby declare that the application has been filled in my own handwriting and all statements made in it are

true, complete, and correct to the best of my knowledge and belief and nothing has been concealed. In the event

of any statement being found false or incorrect or any ineligilbitly being detected before or after the selection, action as

such removal of my name from the rolls and / or other action as may be considered necessary can be taken

aganist me.

2. I also declare that I have carefully read the contents of the Prospectus in respect of the course applied for by

me and undertake to abide by the provision contained therein.

3. I further declare that I fulfil all the eligibility conditions regarding educational qualification, experience etc.

prescribed by the Institute for admission to the course applied for by me.

4. If selected :

(a)I agree to work on whole time basis:

(b)I shall not engage myself in private practice or part time job during the period.

(c)I shall not draw any pay, fellowship or any kind of monetary assistance from any other sources, if I am

allowed emoluments by the Institute.

Place _____________

Date ______________ Signature of the applicant

Address ____________________________________

___________________________________________ Signature

Relationship to the applicant)

ENDORSEMENT BY THE EMPLOYER, IF THE APPLICANT IS IN SERVICE

DECLARATION BY THE FATHER/GUARDIAN OF THE APPLICANT

I hereby declare that I shall be responsible for timely payment of all dues payable to the Postgraduate Institute

of Medical Education & Research, Chandigarh in respect of my son/daughter/ward(name____________________)

during the period of his/her stay at the institute and until their dues are cleared.

No........................... Date ......................

Forwarded to the REGISTRAR, Postgraduate Institute of Medical Education and Research, Chandigarh for consideration. The undersigned has no objection to the applicant of Dr. ______________________being considered bythe Institute for the course applied for by him/her and if selected, he/she will be relieved within, the prescribed timelimit. The applicant is sponspored /deputed or not sponsored /deputed by us and the sponsorship/deputation -certificate is enclosed.

Address ___________________________________ Signature of employer

__________________________________________ with official seal

*Strike out whichever is not applicable

Note:- The closing date for receipt of application will be treated as the date of reckoning for OBC status of the candidate and also for assuming that the candidate does not fall in the creamy layer. The OBC Certificate submitted by the candidate shall be issued by the Competent Authority with in one year of the last date of submission of application.

I......................................................................................................son/daughter of Shri................................................................................................................................................resident of village/town/city...............................................................................district..........................................................state.............................................................................................................................(certificate enclosed) hereby declare that I belong to the ..............................................................................................communitywhich is recognized as a backward class by the Govt. of India for the purpose of reservation in services as per orderscontained in Department of Personnel and Training Office Memorandum No. 36012/22/93-Esstt(SCT)dated 8-9-1993. It isalso declared that I do not belong to the persons/sections (creamy layer) mentioned in coloumn 3 of OM NO. 36012/22/93-Estt (SCT) dated 08-09-1993 and modified vide Govt. of India Department of Personnel and Training OM NO. 36033/3/2004-Estt (Res) dated 09-03-2004

DECLARATION TO BE SIGNED BY OBC CANDIDATES ONLY

Place ..............................

Date ...............................(Signature of applicant)(in running handwriting)

1.


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POSTGRADUATE INSTITUTEPOSTGRADUATE INSTITUTEPOSTGRADUATE INSTITUTEPOSTGRADUATE INSTITUTE OFOFOFOF MEDICALMEDICALMEDICALMEDICAL EDUCATIONEDUCATIONEDUCATIONEDUCATIONANDANDANDAND RESEARCHRESEARCHRESEARCHRESEARCH,,,, CHANDIGARHCHANDIGARHCHANDIGARHCHANDIGARH

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D D D D P / A F P / A F P / A F P / A F 10.09.2014 14.10.2014.10.09.2014 14.10.2014.10.09.2014 14.10.2014.10.09.2014 14.10.2014.

D C 10.09.2014 10.10.2014D C 10.09.2014 10.10.2014D C 10.09.2014 10.10.2014D C 10.09.2014 10.10.2014(2359 ) S B I (2359 ) S B I (2359 ) S B I (2359 ) S B I 14.10.2014.14.10.2014.14.10.2014.14.10.2014.

T T T T 14.10.2014 ( 5.00 P.M.) 14.10.2014 ( 5.00 P.M.) 14.10.2014 ( 5.00 P.M.) 14.10.2014 ( 5.00 P.M.)


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ADMINISTRATIVE STAFFADMINISTRATIVE STAFFADMINISTRATIVE STAFFADMINISTRATIVE STAFF

1. DP . CP . CP . CP . C

MD, DM, FAMS

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F : 0172 2744401, 2744376E : @ .

URL : . . . P : R ,

PGIMER, S 12C 160012

FOR FURTHER ENQUIRFOR FURTHER ENQUIRFOR FURTHER ENQUIRFOR FURTHER ENQUIRP A S P A S P A S P A S 0172017201720172 2755562755562755562755560000 61616161 62626262

SCHEDULESCHEDULESCHEDULESCHEDULE OF E AMINATION AND COUNSELINGOF E AMINATION AND COUNSELINGOF E AMINATION AND COUNSELINGOF E AMINATION AND COUNSELING

E E : 16.11.2014 10:00 A.M.

D R : 17.11.2014 09:00 P.M.

F C : 12.12.2014 11:00 A.M.

S C : 09.01.2015 11:00 A.M.T C : 20.01.2015 11:00 A.M.


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INTRODUCTIONINTRODUCTIONINTRODUCTIONINTRODUCTION

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ADMISSION TO THE POSTGRADUATE COURSESADMISSION TO THE POSTGRADUATE COURSESADMISSION TO THE POSTGRADUATE COURSESADMISSION TO THE POSTGRADUATE COURSES

) A I . T J J .

) T I . C MD/MS J R .

) T I I, I ,

. T E I M J .


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S S S S (SC/ST)(SC/ST)(SC/ST)(SC/ST)S MD/MS

(SC), (ST) , G I ,

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6

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SELECTION PROCEDURESELECTION PROCEDURESELECTION PROCEDURESELECTION PROCEDURE

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INSTRUCTIONSINSTRUCTIONSINSTRUCTIONSINSTRUCTIONS FOR ENTRANCE E AMINATIONFOR ENTRANCE E AMINATIONFOR ENTRANCE E AMINATIONFOR ENTRANCE E AMINATION

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M IS M B I .


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FEES AND DUESFEES AND DUESFEES AND DUESFEES AND DUES

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ANNE URE 1: INSTRUCTIONS FOR PHOTOGRAPHSANNE URE 1: INSTRUCTIONS FOR PHOTOGRAPHSANNE URE 1: INSTRUCTIONS FOR PHOTOGRAPHSANNE URE 1: INSTRUCTIONS FOR PHOTOGRAPHS

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ANNE URE 2: FORMAT OF SC/ST CERTIFICATEANNE URE 2: FORMAT OF SC/ST CERTIFICATEANNE URE 2: FORMAT OF SC/ST CERTIFICATEANNE URE 2: FORMAT OF SC/ST CERTIFICATE

FFFF M.H.A., O.M., N . 42/21/49 M.H.A., O.M., N . 42/21/49 M.H.A., O.M., N . 42/21/49 M.H.A., O.M., N . 42/21/49 N.G.S. D 28.01.1952, N.G.S. D 28.01.1952, N.G.S. D 28.01.1952, N.G.S. D 28.01.1952, D . PD . PD . PD . P & A.R, N . 36012/6/76& A.R, N . 36012/6/76& A.R, N . 36012/6/76& A.R, N . 36012/6/76 E . (S.CT), E . (S.CT), E . (S.CT), E . (S.CT), 29.10.1997, 29.10.1997, 29.10.1997, 29.10.1997,

S C S T S C S T S C S T S C S T / .

/ . / . / .

CASTE CERTIFICATECASTE CERTIFICATECASTE CERTIFICATECASTE CERTIFICATE

T S /S ./K .*............................................................................ / * ................................................ /T * ................................................. /D *................................................. S /U T *...............................................

...............................................C /T S C /S T * : T C (S C ) O , 1950 T C (S T ) O , 1950 T C (S C ) (U T ) O , 1951 T C (S T ) (U T ) O , 1957

%1. ( S C S T L (M ) O , 1956, B R A , 1960, P R A , 1966, S HP A , 1970, N E A (R ) A , 1971 S C S T O ,(A ) A , 1976)

T C (J K ) S C O , 1956 T C (A N I ) S T , O , 1959 T C (D N H ) S C O , 1962 T C (D N H ) S T O ,1962 T C (P ) S C O , 1964 T C (U P ) S T , O ,1967 T C (G , D & D ) S C O , 1968 T C (G , D & D ) S T O , 1968 T C (N ) S T O , 1970 T C (S ) S C O , 1978 T C (S ) S T O , 1978.%2. A S C /S T S /U T A :T S C /S T S /S *.......................................... / S /S /K * ................................................

/ *......................................... D /D *........................................... S / UT *....................................... ..................................... / S C /S T * S /U T *......................................................................... .......................................................... (

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S ...............................P ....................... S /U TD ........................ ( ) **D ...............................

* P . P P O .% D .** S A S C /S T

.


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20

ANNE URE 3: FORMAT OF OBC CERTIFICATEANNE URE 3: FORMAT OF OBC CERTIFICATEANNE URE 3: FORMAT OF OBC CERTIFICATEANNE URE 3: FORMAT OF OBC CERTIFICATE

CERTIFICATE TO BE PRODUCED B OTHER BACK ARD CLASSES APPL ING FORCERTIFICATE TO BE PRODUCED B OTHER BACK ARD CLASSES APPL ING FORCERTIFICATE TO BE PRODUCED B OTHER BACK ARD CLASSES APPL ING FORCERTIFICATE TO BE PRODUCED B OTHER BACK ARD CLASSES APPL ING FORADMISSION TO CENTRAL EDUCATIONAL INSTITUTADMISSION TO CENTRAL EDUCATIONAL INSTITUTADMISSION TO CENTRAL EDUCATIONAL INSTITUTADMISSION TO CENTRAL EDUCATIONAL INSTITUTIONSIONSIONSIONS (CEIS)(CEIS)(CEIS)(CEIS) UNDERUNDERUNDERUNDER THETHETHETHE

GOVERNMENT OF INDIAGOVERNMENT OF INDIAGOVERNMENT OF INDIAGOVERNMENT OF INDIA(G.I., D . P . & T ., O.M.N . 36033/28/94 E . (R ), 02.07.1997)

T S /S ./K .................................................................................. /............................................................... / .................................

D /D .................................................................. S /U T............................................... .........................................................

B C :

*( ) G I , M , R N . 12011/68/93 BCC (C), 10 S ,1993, G I , E , P I, S

I, N .186, 13 S , 1993.*( ) G I , M , R N . 12011/9/94 BCC,

19 O , 1994, G I , E , P I S I, N .183, 20 O ,1994.

*( ) G I , M , R N . 12011/7/95 BCC, 24M , 1995, G I , E , P I, S I, N . 88

25 M 1995.

*( ) G I , M , R N . 12011/44/96 BCC, D 6 D , 1996, G I , E , P I, S I, N .210, 11 D 1996.

*( ) G I , M , R N . 12011/09/2004 BCC, D 16 J , 2006, G I , E , P I, S I, N .210, 16 J 2006.

S ./S ................................................................................ / ( ) ........................................................................ D /D ............................................................... ST / / (C L )

C 3 S G I , D P T , O.M. N . 36012/22/93 E . (SCT), 08.09.1993 O.M.

N .36033/3/2004 E . (R .) 09.03.2004 G I .

(S )N .............................. D MD ........................ D C .

* P .


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ANNE UREANNE UREANNE UREANNE URE 4444: FORMAT OF RURAL AREA CERTIFICATE: FORMAT OF RURAL AREA CERTIFICATE: FORMAT OF RURAL AREA CERTIFICATE: FORMAT OF RURAL AREA CERTIFICATE

RURAL AREA SERVICE CERTIFICATERURAL AREA SERVICE CERTIFICATERURAL AREA SERVICE CERTIFICATERURAL AREA SERVICE CERTIFICATE

T D . ................................................................................... /

S .................................................................................................... R N

......................................... (

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T / 30 J /31 D J &

J .


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ANNE URE 5: FORMAT OF SPONSORSHIP CERTIFICATEANNE URE 5: FORMAT OF SPONSORSHIP CERTIFICATEANNE URE 5: FORMAT OF SPONSORSHIP CERTIFICATEANNE URE 5: FORMAT OF SPONSORSHIP CERTIFICATE

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N : S P H /IN : S P H /IN : S P H /IN : S P H /I /N/N/N/N H , . H , . H , . H , .

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