POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH APPLICATION FORM FOR THE ADMISSION IN MD/MS, DM/M.

CH/ HOUSE JOB ORAL HEALTH/MHA COURSES

(Form for the Computer)
INSTRUCTIONS
1. Please read the information given in the prospectus carefully before filling up this Application form. 2. This application form should reach on or before 27-09-2010 3 Fill in CAPITAL LETTERS

SESSION-JANUARY 2011
Roll No.

Form No.

For Office use only

CANDIDATES NAME (Don't Write Shri or Doctor) FATHERS NAME MOTHERS NAME ADDRESS FOR COMMUNICATION (Please do not REPEAT your name and fathers name) CITY PIN CODE

DATE OF BIRTH DAY MONTH YEAR

NATIONALITY 1 2 Indian Foreign.

GENDER 1 Male 2 Female

---------------------------------------------------------------------------------------------------------------------------------------CATEGORY 1. 2. 3. 4. General OBC Schedule Caste Schedule Tribe 5. 6. 7. 8. Rural Area Services Ortho. Physical Handicaped Sponsored/ Deputed Foreign National COURSE 1. MD/MS 2. DM/ M.Ch 3. House Job (Oral Health Sciences) 4. MHA

For Category 7 or 8 mention name of the subject

Aggregate % age marks in MBBS/BDS

MBBS/BDS

MD/MS

Date of Completion of Internship

Employed 1=Yes 2=No

%
(Enter Max. attempts taken in any of MBBS/BDS, MD, MS exam.) Day Month Year

BANK DRAFT NO. ................................................................in favour of Director , PGI, Chandigarh. Date of issue ................ Bank Name / Branch ................................................................................................................................................................. ........................................................................................................................Amount Rs..........................................................

Declaration I have carefully read the instructions given in the prospectus. I hereby solemnly and sincerely affirm that the statement made and the information furnished by me with application form are true and correct. If however, it is found that any information furnished here in is fraudulent, incorrect or untrue in material particulars, I realize that I am liable to criminal prosecution and my selection and admission to the course is liable to be cancelled.
Date : Signature of the Candidate

POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH,

SESSION:

January 2011 FOR DM/M.Ch ONLY........................... Roll. No.

(for office use)_____________

TO BE FILLED BY THE CANDIDATE ITSELF BELOW THIS LINE: ______________________________________________________

1. Name: Dr....................................... Superspeciality applied for.......................................... 2. Wheather applied for other superspeciality, if yes name of subject(s)..........................................................

INFORMATION LIST
1. 2. 3. 4. 5. 6. 7. Has the candidate passed MBBS examination from a Medical Collage recognized by MCI? Attempts made by the candidate during his/her MBBS career. Has the candidate passed MD/MS examination from a recognized college or apearing. Attempts made by the candidate during his/her MD/MS career Subject in which MD/MS examination passed Date of Birth Nationality

YES / NO ____________

____________ ____________ ____________ ____________ ____________

DECLARATION
I have carefully read the Instructions given in the prospectus. I hereby solemnly and sincerely affirm that the statement made and information furnished by me with application From are true and correct. If, however, it is found that any information furnished herein is Fraudulent, incorrect or untrue in material particulars, I realize that Iam liable to criminal prosecution and my selection and admission to the course is liable to be cancelled

Dated__________

Signature of the Candidate

______________________________________________________________________
FOR OFFICE USE ONLY
1. 2. The application is complete in all respects. Candidate is Eligible The application is incomplete for want of the following documents and may be filled as per the conditions of general information in propectus. 1. 4. Attempt-MBBS Sponsorship Certificate 2. 5. Attempt-MD/MS NOC 3. 6. Caste Certificate ________________

3.

We may inform the candidate accordingly. The candidate has more than one/ two failures during MBBS/MD/MS career and is NOT Eligible.

1.

SESSION : January 2011 For MD/MS Course only

/ Country

Price:

Rs. 500/- For general/OBC/OPH (including prospectus) for MD/MS, MHA Rs. 400/- For SC/ST (For DM/M.C.h (including prospectus) Rs. 500/- only

Session: January, 2011 Form No._____________

Postgraduate Institute of Medical Education & Research, Chandigarh 160012

Application form for ________________ Speciality Applied for (in case of BM/M.ch.)__________________ Application form duly completed should reach the Office Of The Registrar by 27.09.2010 Roll No.
(FOR OFFICE USE) Dy. No................................................. Date ...................................................

IMPORTANT NOTE: BEFORE FILLING UP THIS APPLICATION FORM PLEASE READ THE ADMISSION NOTICE AND THE PROSPECTUS SUPPLIED WITH THIS FORM CAREFULLY REGISTRAR Postgraduate Institute of Medical Education & Research, Chandigarh - 160 012 Sir, I submit my application for admission to the course ticked ( ) below
MD/MS DM/M.Ch. MHA House Job(Dentistry) Please paste here a passport size coloured photograph attested by the Gazetted Officer With Date and Name

Subject: __________________________________________________ a) For Sponsored & foreign MD/MS candidates, mention upto three subjects for which they have been sponsored. b) For DM/M.Ch. _______________________________________ (The candidates are required to submit separate application for each subject they want to apply for) c) I am an applicant under the category ticked ( 1. 2. 3. 4. 5. 6. 7. 8. General OBC Sch. Caste Sch. Tribe Rural Area Service Orthopaedic Physically Handicapped (Column No. 2,3,4,5,6 are not applicable to DM/M.Ch. courses) Sponsored / Deputed _______________________________ (Also mention subjects) Foreign National ____________________________________ (Also mention subjects) one category only)below:-

(to be filled only by the candidates who download the form websites) Bank Draft No.: ........................................ in favour of Director, PGI, Chandigarh (Rs. 500/- for Gen./OBC/OPH and Rs. 400/- for SC/ST) Date of issue ........................................... Name of the issuing Bank/ Banch........... .................................................................. Amount Rs. ..............................

Yours faithfully

(Note : The Change of category at any stage will not be permitted) ( Place______________________

(Signature of the Candi date)

__________________________ Name in Block Letters)

Date _____________________

The application form and acknowledgement card must be completed in the candidates own handwriting using ball point pen. An application which is incomplete or wrongly filled in, will be rejected. 1. (a) (b) 2. 3 (i) Name in full (in block letters) (In English) In Hindi (Devnagari Script) : :
:

________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________

Date of birth (as recorded in matriculation or its equivalant certificate according to Christan Era)

(a) (b)

Fathers Name (In English) In Hindi (Devnagri Script) Mothers Name (In English) In Hindi (Devnagri Script)

: : : : :

(ii)

(a) (b)

4.

Fathers occupation and annual income

5. (a)Do you belong to Scheduled Caste/ Tribe/OBC : (b)If yes, state your caste and religion (attach proof) 6. 7. 8. 9. 10. Gender : :

Married or unmarried (If married, wife/husband name & occupation): Nationality State/Union Territory to which you belong Address in Block letters (a) (b) (c) (d) (e) Where interview / selection letter etc. should be sent Permanent Home Address Telegraph address (if any) : : : :

________________________________________________ ________________________________________________

Telephone No. STD Code & Mobile Number : ________________________________________________ E-mail address (if any) : ________________________________________________ ________________________________________________ ________________________________________________

11. 12.

Permanent Medical Registration number and the state in which registered : Are you doing / have done MD/MS in which subject :

12 A. Are you employed if yes, give the following detials (a) (b) (c) (d) (e) (f) Note: Date of joining as regular service Nature of job : : ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________

Name of the Institution/Hospital Govt./ Semi Govt. / Pvt. : Designation Pay Scale Name of employer : : :

If you are doing/ have done MD/MS, you are not eligilble for applying for MD/MS Coures. Please refer to the point d of General information of the prospectus. 3

13.

(A) (a) (b)

Details of MBBS/BDS/MD/MS Examination A failure in the examination, compartment or re-appear in one or more subjects will constitute an attempt. The attempts made at passing the examinations should be mentioned as FIRST i.e. No. failure/No compartment/ No re-appear) SECOND (i.e. one failure/ compartment/ re-appear etc) and not as ONE or TWO etc.)
Name of University/ Institute Month & Year in Which passed Attempt at which Passed Proof at encl. No.

Examination passed

First Professional Second Professional Third Professional Final Professional Aggregate Percentage of marks obtained in the MBBS/BDS Examination __ 13. (B) Details of intership or compulsory rotatory house job. Days From MM Yrs. To Days MM Yrs. Date of Proof at Encl. No. completion

Name of Hospital

13.

(C)

Postgraduate examination passed

A. Name of University/ Institute B. Month & year in which passed Whether of MD/ MS is Recognized by MCI, If yes enclosed Proof Whether college/ Institution is Recognized by MCI if yes enclosed proof Attempts at which Passed Proof at Encl. No. If appearing in which Subject

Name of examination Name of the college Passed and from which the the subject candidate passed

14.

Have you worked / are working / or doing private practice in rural area for a period of two years of more? If so, give details. Name of Hospital Place Capacity in which Pay scale Worked From Period to Yr Month Proof at Days Encl. No.

15.

Give names and complete address: of two references not related to you

1.

_______________________________________________ _______________________________________________

_______________________________________________

2.

______________________________________________

_______________________________________________ _______________________________________________

_______________________________________________

16.

Have you any contact person/guardian in Chandigarh. If so, mention his/ her address Telephone No., If any.

_______________________________________________ _______________________________________________

17.

Are you being sponsored/ deputed by your employer? If sponsored, the application must be accompanied with sponsorship, deputation certificate in the form printed at page 8.

_______________________________________________

Date ___________________ Place __________________ Note- PLEASE DO NOT LEAVE ANY COLUMN UNFILLED/BLANK 5 ( ______________________________) Signature of the applicant

ATTEMPT CERTIFICATE
The application must accompany the undermentioned certificates duly signed by the Principal of Medical College/ Institute from where the candidates has passed his/her MBBS/MD/MS/BDS Examination. NB 1. The failure of candidate in any professional MBBS/BDS examination or his/her having been placed in compartment or re-appear in one or more subjects shall constitute as an attempt. 2. The entries under the headingcolumn at which passed should be indicated as FIRST (i.e., no failure/ Compartment/re-appear), SECOND (i.e., one failure/compartment/re-appear) etc. and not as ONE, TWO etc. 3. Candidate may attach the photocopy of attested certificates issued by the Medical College/Institute

ATTEMPT CERTIFICATE - I

MD/MS/,House Job/MHA

Certificate that Dr. __________________________________________________________________________ son/daughter of Sh. ______________________________________________________________________________ has passed professional examination of the MBBS/BDS course as per details given below:Examination Attemped at which passed. 1. 2. 3. 4. First Professional Second Professional Third Professional Final Professional _______________________________ _______________________________ _______________________________ _______________________________

It is certified that MBBS/BDS degree of this Medical/Dental College is recognized by the Medical Council/ Dental Council of India. It is certified that ___________________________________________ commenced his/her rotatory compulsory internship training on ____________________ and is due to complete the same on _________________ OR It is certified that _______________________________________ has completed his/her compulsory rotatory internship on ______________________________________ Session : __________________ Signature __________________ Designation ________________ (Official Seal)

ATTEMPT CERTIFICATE - II

(DM/MCh)

Certificate that Dr. _____________________________ son/daughter of Sh. ________________________________ has passed the MD/MS examination from the Institute / Unviersity in the subject of _____________________ in the ________________ attempt(s). It is certified that the above said MD/MS degree of the Institute/University is recognized by Medical Council of India. It is further certified that the degree of MD/MS of College/Institution in the subject of _________________________ awarded to him/her is recognized by the Medical Council of India as per their letter No. ________________________ A photocopy of the same is enclosed. Station ____________________ Date ___________________ Signature _______________ Designation ______________

Official Seal _______________ Note : 1. Deletion /alteration of any word in the above certificate will lead to rejection of the application summarily and no intimation will be sent to the candidate. 2. In case a photocopy of the letter from the Medical Council of the India Postgraduate Degree College/ Institution is not enclosed, the application will not be considered. 6

DECLARATION BY CANDIDATE
1. I hereby declare that the application has been filled in my own handwriting and all statements made in it are

true, compelete, 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 such as removal of my name from the rolls and / or other action as may be considered necessary can be taken aganist me. 2. 3. 4. 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. 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. 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

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 is respect of my son/daughter/ward(name____________________) during the period of his/her stay at the institute and until their dues are cleared. Address _____________________________________ ___________________________________________ ( Signaute Relationship to the applicant) )

ENDORSEMENT BY THE EMPLOYER, IF THE APPLICANT IS IN SERVICE

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 by the Institute for the course applied for by him/her and if selected, he/she will be relieved within, the prescribed time limit. The applicant is sponspored /deputed or not sponsored /deputed by us and the sponsorship/deputation certificate is enclosed. Address ___________________________________ __________________________________________ *Strike out whichever is not applicable
DECLARATION TO BE SIGNED BY OBC CANDIDATES ONLY I......................................................................................................son/daughter of Shri................................................................ .........................................resident of village/town/city........................................................ district..........................................................state............................................................community............................................... (certificate enclosed) hereby declare that I belong to the ..............................................................................................community which is recognized as a backward class by the Govt. of India for the purpose of reservation in services as per orders contained in Department of Personnel and Training Office Memorandum No. 36012/22/93-Esstt(SCT)dated 8-9-1993. It is also declared that I do not belong to the persons/sections (creamy layer) mentioned in coloumn 3 of OM NO. 36012/22/93Estt (SCT) dated 08-09-1993 and modified vide Govt. of India Department of Personnel and Training OM NO. 36033/3/2004Estt (Res) dated 09-03-2004
Place (Signature of applicant) (in running handwriting)

Signature of employer with official seal

Date 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.

RURAL AREA SERVICE CERTIFICATE

Certified that Dr. _____________________________________________________________ son/daughter of Shri ________________________________ Registration No. ____________________ has served or carried on private practice in the following place(s) during the period indicated against each: Place Days From Months Years Period Days To Months Years

Certificate that the above mentioned place comprises a village or a Primary Health Centre of town with population of less than 5000 and without a municipal area. Date __________________ Station __________________ Signature of the Distt. Magistrate with seal

SPONSORSHIP CERTIFICATE (Applicable only in case of candidates who are sponsored/deputed) Note : Sponsorship for Private Hospital/Institute/Nursing Homes, etc. is not accepted.
Certified that Dr. _______________________________________________________________ son/daughter of Shri _____________________________________________ is a permanent / regular employee of the Govt. Deptt/ Medical College since _________________________ (Date) and has THREE YEARS of Regular/Permanent Service. Please ( ) the type of Institution/ Department sponsoring / deputing the candidate viz. I. Central Govt. 2. State Govt. 3. Autonomous Body of Central Govt. 4. Autonomous Body of State Govt. 5. Public Undertaking 6. Medical College / Hospital affiliated to a University and recognized by Medical Council of India. Certified that if selected for the course applied for by the applicant he/she will be suitably employed by us after the completion of his/her training course to work for atleast five years in the speciality in which the training is received by him/her at PGI, Chandigarh. Certificate that no financial implication in the form of emoluments/stipend etc. will devolve upon PGI, Chandigrh during the entire period of applicants course. Such payment will be the responsibility of sponsoring/deputing authority. Signature of the sponsoring/ deputing authority with seal

1.

2.

3.

Date ________________ Station _____________

NB 1.Deputation /Sponsorship of candidates holding tenure appointment (like House Job or Junior or Senior or Senior Residency), adhoc or contract or honorary or appointment aganist a leave vacany shall not be accepted. 2. The sponsoring/deputing Institution should not nominate more than one candidate for a speciality/ super speciality. 3. The candidate must indicate the subject or thier choice in the application clearly as page 1. Sponsoring / deputation of candidates will be accepted only from the following.: (a) Central Govt. Departments/ Institution (b) State Govt. Departments/ Institution (c) Autonomous bodies of the central or State Govt. (d) Public Sector Undertakings. (e) Medical College affilated to a University and recognized by the Medical Council/Dental Council of India. In case of candidates deputed/ sponsored by Medical College affiliated to a University and recognized by the Medical Council of India, the deputation/ sponsorship certificate signed by the Principal of Medical College concerned only shall be accepted. Note: The three photograhs to be pasted on this form at the place indicated must be identical.The photograph should be signed by the candidate in ink on the front. 8

APPLICATION MUST BE TAGGED PROPERLY & ALL THE ENCLOSURES MUST ACCOMPANY THE APPLICATION IN SEQUENCE AS PER THE ENCLOSURE LIST GIVEN BELOW
Documents 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Attested copy of Matriculation / Higher Secondary Certificate Showing Date of Birth Attested copy of Certificate of passing MBBS/BDS examination Attested copy of Certificate of passing MD/MS examination Internship completion certificate Attempt certificate I and II in signed by principal, Dean / Registrar Attested copy of certificate of the character and conduct from the Institution last attended. Attested copy of Certificate of permanent Registration with Central / State Medical Registration Council / Dental Council of India Attested copy of Caste Certificate in Hindi/English Script Sponsorship/deputation Certificate in the prescribed form, if applicable Enclosure No. _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ _________________________

Two self addressed envelopes of size 10x23 cms. Rs. 10/- Postage stamp _________________________ on each envelope for use by this office for sending interview letter etc. _________________________ Rural Area Certificate issued by Distt. Magistrate Orthopaedically handicap certificate (if applicable) OBC certificate should be signed by District Magistrate (if applicable) _________________________ _________________________ _________________________

IMPORTANT NOTE In case any candidate is found to have supplied false information of certificate etc. or is found to have concealed or withheld some information in his/her application form, He/she shall be debarred from admission. Any other action that may be considered appropriate by the Director of the Institute may also be taken against him/her which may include criminal prosecution.

Date _______________________________ Place _____________________________ No. of Enclosures : ___________________ 9

Signature of the Candidate

POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH - 160012

SELECTION OF CANDIDATE FOR MD/MS, DM//MCh, MHA, HOUSE JOB (ORAL HEALTH) COURSES
Session Jan 2011 1. Category_________________ Roll No.

ADMIT CARD

(For office use)

2. 3.

4.

Please paste here a Passport size Name of the Candidate______________________________________________ coloured photograph with name & date attested by the Gazetted Officer Specimen signature of the candidate_____________________________________ Examination Centre: Chandigarh

The photograph along with the specimen signature are affixed thereon to the selection test for MD/MS, DM/M.Ch.,MHA, House Job (dentistry) mentioned above. REGISTRAR Postgraduate Institute of Medical Education & Research,Chandigarh.

POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH - 160012

SELECTION OF CANDIDATE FOR MD/MS, DM//MCh, MHA, HOUSE JOB ( ORAL HEALTH) COURSES
Session Jan 2011

Candidates Attendence Sheet

Roll No.

(For office use) 1. Category_________________ Please paste here a Examination Centre: Chandigarh Passport size coloured photograph with name Name of the Candidate______________________________________________ & date attested by the Gazetted Officer Specimen signature of the candidate_____________________________________

2. 3. 4.

ATTENDANCE SHEET Date and Time

(Nothing to be written below this line by candidate) Fill in Examination Center only Signature of candidate ( to be signed in Examination Hall) signature of Invigilator

10