(Www.entrance-exam.net)-Application Form for Eligibility Certificate

7/30/2019 (Www.entrance-exam.net)-Application Form for Eligibility Certificate

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DENTAL COUNCIL OF INDIA(Ministry of Health & Family Welfare, Govt. of India)

A I WA N - E- G A LI B M A R G, K O T LA R O AD , N E W D E L HI - 11 0 0 0 2

A p p l i ca t i o n F o r m f o r E l i g i b il i t y C e r ti f i c at e f o r g e t t in g a d m i s si o n t oGraduate / Post Graduate Dental Courses from a Foreign Dental Institution

(As per the procedure for obtai ni ng the 'El igi bi l i ty Certi fi cate' pri or to admissi ons i n any authority/ i nsti tuti onoutsi de I ndi a under Regul ati on 16 of DCI Screeni ng Test Regul ati ons, 2009)

Appl i cati on Form No.

1

DENTALCOUNCILOF INDIA

5. Date of Birth

D D M M Y Y Y Y

4. Sex

Male F em ale

BDS PG DI PLOMA MD S

A PPLIC ATION FOR ELIGIB ILITY C ER TIFIC ATE FOR

11 . E - m a i l ( W r i te i n B o l d & C l e a r m a n n er ) , if a ny

12. S TD C ode Telephone N um ber

14. Nationality

ii) Passport No., if any

iii) Date of Issue

D D M M Y Y Y Y

i) By Birth/By Domicile

D D M M Y Y Y Y

vi) Date upt o which v alid v ) Plac e of I ssue

PHOTOGRAPH

1.

2.

3.

4.

P a s t e he r e ( do n o t p i n o r s t e p l e)a r e ce n t p a s s p or t s i z e c ol o u r photograph with

.name plate

b e a r in g n a m e & d a t e o n i t

T h e p h o t o g r a p h s h o u l de x c e e d t h i s b o x .

NOT

I f t h e ph o t og r ap h i s no t c l e ar ,t h e a p p l i c a t i o n w i l l b e r e j e c t e d .

T h e p h o t og r ap h t o b e a ff i xe d h e reshould be attested.N OT

T O B E F I LL E D I N C A PI TA L L E TT E R O NLY

( R e ad i n s t r uc t i o ns c a r e f ul l y b e f or e f i l l in g u p t h e F o r m)

1. Name (CAPITAL LETTERS) (Leave a blank space between first, middle & last names)

2. Father's/Husband's Name

3. Mother's Name

9. Present Address

Name:

Address:

City:

State:

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Pin Code :

10. Permanent Address

Name:

Address:

City:

State:

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Pi n Code :

6 . A g e (a s o n 3 1s t D e c . o f a dm i s s i o n y e a r )

DAYSMONTHSYEARS

7 . C a t eg o ry ( G en e ra l /S C /S T / OB C / Ot h er s ) 8 . T wo v i si b le i d en t if i c at i o n m a rk s

a) b)

13. Mobile Number

MSN


2/5

15. Details of the qualifying Examination passed

2

Name of School:

Address:

City:

State:

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Name of Board:

Address:

City:

State:

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Pin Code : Pi n Code :

Month & Year of CompletionDate of Joining

M M Y Y Y Y M M Y Y Y Y

R oll No. R es ult

Subjects Maximum marks Marks Obtained %ageResult(Pass/Fail)

English

Physics

Chemistry

Biology

Additional subject,if any,

i)

ii)

iii)

iv)

v)

G R A N D T O TA L

PracticalTheoryPracticalTheory

16. B.Sc. or any other University Examination (If any):

Name of Institution:

Address:

City:

State:

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Name of University:

Address:

City:

State:

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Pin Code : Pi n Code :

Month & Year of CompletionDate of Joining


R oll No. R es ult

Subjects Maximum marks Marks Obtained %ageResult(Pass/Fail)

English

Physics

Chemistry

Biology

Additional subject,if any,

i)

ii)

iii)

iv)

v)

G R A N D T O TA L

PracticalTheoryPracticalTheory

MSN


3/53

1 7 . B D S o r e q ui v a l en t c o u rs e ( I f a n y ) :


Address:

City:

State:

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Name of University:

Address:

City:

State:

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Pin Code : Pin Code :


Address:

City:

Stat e: C ount ry :

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

Name of University by which the degree is to be awarded:

Address:

City:

St at e: Count ry:

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Pin Code : Pin Code :

M o n t h & Ye a r o f C o m p l e t i onDate of Joining


Roll No. Result

Subjects

i)

ii)

iii)

iv)

v)

vi)

vii)

viii)

ix

x)

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G R A N D T O TA L

Maximum marks M ark s Obtained %ageResult(Pass/Fail)PracticalTheoryPracticalTheory

18. Details of the Foreign Dental College/Institution at which Admission Is sought by the Candidate

1 9 . C o m p l et e d e t a il s o f t h e d e nt a l c o u r s e f or w h i c h t h e e li g i b i li t y c e r t i f ic a t e i s b e i n g s ou g h t .

a). Name of the Course.

MSN


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Signature of the Applicant

Place: Date:

4

i) Duration ii) R orat ory /Otherwise

20. Details of payment of fees :

Eligibility Certificate Fee: CASH DD

(i) Paid by Cash/Demand Draft of Rs. 1,000.00 (Rs. One thousand only)

(ii) If paid by demand draft, details thereof :

Name and address of issuing bank

Demand Draft Number and date

Amount Rs.

Pay Order

b). Whether the course is recognised by their respective country/councils/governments for practice purpose, if yes

c ) . W h e t h er a n a t t e s t e d c o py o f r e g i s t r at i o n o f t h e S t a t e D en t a l C o u n c il o f t h e r e s p e ct i v e c o u n tr y h a s b e e n e nc l o s e d.

d). Whether the course is recognised for PG teaching in respective university/institution.

e). Duration of the course.

f). Whether the duration of the course is at par with the same course conducted by Indian Institution.

g). Exact Date of commencement of the academic session.

h). Tentative date of completion of the course.

i ) . W h e t h er t he co u r s e i s a f u l l t i m e .

j). Whether the course is an in-house course and not an online course or correspondence course.

k). Whether the eligibility criteria for admission in terms of educational qualification, age, percentage etc. is similar to the

Indian universities, if yes (give the details)

l). Is there any Internship provision (if yes, give the details):

Yes N o

Yes N o

Yes N o

m). Whether the course content are similar to that of India. Yes N o

n). Whether the examination pattern is similar to that of India. Yes N o

o). Whether the subject wise teaching hours are similar to that of India.

If yes, please indicate the following details

Yes N o

p). Whether a copy of prospectus indicating the syllabus as well as other informations have been enclosed Yes N o

To t a l H o u r s Clinical Academic Field

In case of PG courses, please indicate (on a separate white sheet) subject of specialization, Thesis, Clinical work requirement, Seminars,

Journal Club, No. of Conferences to be attended, Examination pattern, Faculty details (if any).

MSN


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5

DECLARATION

I d e cla re th a t th e e n trie s ma d e b y me in th is Fo rm a re tru e to my kn o wle d g e a n d I u n d e rsta n d th a t I a m lia b le

fo r a ctio n u n d e r th e la w fo r a n y fa lse in fo rma tio n o r d o cu me nt p ro d u ce d b y me with o u t a n y n otice fro m DCI, Ne w

De lh i.

I a lso u n d ersta n d th a t th e De n ta l Co u n cil o f In d ia sh a ll b e fre e to in ve stig a te o n its o wn in to th e co rre ctn e ss

o f in fo rma tio n fu rn ish e d b y me in th is a p plica tio n a n d /o r ca ll fo r a n y fu rth e r in fo rma tio n in th is re g a rd fro m me a n d in

th e e ve n t o f a n y in fo rma tio n fu rn ish e d b y me b e in g fo u n d to b e in co rre ct o r fa lse d u rin g su ch in ve stig a tio n o r a t a n y

su b se q u e n t sta g e , th e Co u n cil ma y re fu se to issu e th e e lig ib ility ce rtifica te o r if a lre a dy issu e d ma y ca n ce l th e sa me

a n d I sh a ll sta n d d e b a rre d fro m a p p e a rin g in th e Scre e n in g Te st p re scrib e d in De n ta l Co u n cil o f In d ia Scre e n in g

Te st Re g u la tio n s, 2 0 0 9 a n d a ny o th e r ru le a n d re g u la tio n fra me d by DCI, Ne w De lh i with o u t a n y n o tice .

I u n d e rsta n d th a t a fte r ob ta in in g th e fo re ig n re cog n ize d p rima ry d e n ta l q u a lifica tio n , a n d su b ject to th e

ve rifica tio n a s co n ta in e d a b o ve , I h a ve to p a ss a scre e n in g te st p re scrib e d u n d e r th e De n tists Act, 1 9 4 8 re a d with

th e Pro ce d u re fo r o b ta in in g th e 'Elig ib ility Ce rtifica te ' p rio r to a d missio n s in a n y a u th o rity/in stitu tio n o u tsid e In d ia in

a De n ta l Co u n cil o f In d ia Scre e n in g Te st Re g u la tio n s, 2 0 0 9 b e fo re g ra n t o f Re g istra tio n b y a n y o f th e Sta te De n tal

Co u n cil.

(Sig n a tu re o f Ca n d id a te )

Da te : ........................................

Pla ce : .......................................

1 ) I n co m pl e te d oc u me n ts w il l n o t be a cc e pt e d. Ap p li c at i on m us t b e c o mp l et e in a ll r e sp e ct s . No a lt e r at i on w il l b e al l ow e dto be made i n the appl i cati on form after i t has been submi tted to the Counci l .

2 ) T h e F o rm sh o ul d b e f i ll e d u p u s in g C a pi t al l e tt e rs in ca n di d at e s ow n l e gi b le ha n dw r it i ng .

3 ) D e ma n d d r af t fo r Rs . 10 0 0/ - (R u pe e s O n e T h ou s an d o n ly ) i n f a vo u r o f T he Se c re t ar y, De n ta l C o un c il o f I n di a ,payabl e at New Del hi . On reverse of demand draft pl ease menti on appl i cants Name, Father s Name, purpose for whi ch the draft submi tted and Tel ephone Number. In case payment i s made in cash then i t wi l l be made onl y to

authori zed offi cer in accounts secti on. A copy of recei pt wil l be attached wi th the appl i cati on and detai l s of suchpayment fi l l ed by appl i cant i n the form. No payment wi ll be made i n cash to any person of DCI at the counter, or anywhere el se except i n account secti on.

4 ) A p pl ic a nt i s r eq u ir e d to a ff i x on e r ec e nt f r on t v ie w p h ot o gr a ph o n t he a p pl i ca t io n f or m a nd a l so a t ta c h th r ee p a ss p or tsi ze photographs.

5 ) A l l t h e do c um e nt s sh o ul d b e s u bm i tt e d i n o r ig i na l ( a lo n gw i th t hr e e l e gi b le a tt e st e d p h ot o co p ie s )

6 ) O r ig i na l M a tr i cu l at i on Ce r ti f ic a te sh o wi n g D a te of B ir t h ( w it h th r ee at t es t ed ph o to c op i es . )

7 ) O ri gi na l M a r ks he et of t he 11 th cl as s (w it h t hr ee at t es te d p ho to co pi es ).

8 ) O ri gi na l + 2 M ar ks he et & p as s C er t if ic at e (w it h th re e a tt es te d p ho to co pi es ).

9 ) O r ig i na l S C /S T /O BC C e rt i fi c at e ( w it h t h re e a t t es t ed ph o to c op i es ) ( i n c a se o f r e se r ve d c a te g or y c a nd i da t es ) a n d acopy of Engl i sh Versi on i n case of Caste Certi fi cate i s i n regi onal l anguage.

1 0 ) O r ig i na l P r oo f o f A d mi s si o n in F o re i gn D e nt a l U n iv e rs i ty ( a lo n gw i th t h r ee a t te s te d p ho t oc o pi e s)11 ) A p pl i ca n t to r et a in o ne c op y of a pp l ic a ti o n f o rm a nd d r af t f or f u tu r e r e fe r en c e.

1 3 ) A c o py o f p r o sp e ct u s/ b ro u ch e r i nd i ca t in g c o mp l et e d e ta i ns i n r e sp e ct o f s y l la b us , c o ur s e c ur r ic u lu m , a dm i ss i oncri teri a etc. i ssued by the Dental Insti tuti on outsi de India for whi ch the candi date has sought the el i gi bi l i ty certi fi cate.

1 2 ) P r oo f o f re c og n it i on o f t he C o ur s e wi t h th e r es p ec t iv e d en t al c o un c il o r a ny o t he r c om p et e nt a u th o ri t y o f t he c o un t ry f o r whi ch the appl i cant has sought the el i gi bi l i ty certi fi cate.

INSTRUCTIONS

(Read Instructi ons careful l y before fi l l i ng up the El i gi bi l i ty Form)

MSN

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(Www.entrance-exam.net)-Application Form for Eligibility Certificate