Date: 27-01-2022

Important Instruction for Post Graduate Students

 All the admitted students are required to report at the Institute between – 10:30 AM
to 01:30 PM & 3:00 PM to 05:00 PM
 Students are required to bring cheque book for submitting 5 PDCs (Post Dated
Cheques) of their remaining tuition fees.
 Students are required to bring Demand Draft in the name of “GUJARAT ADANI
INSTITUTE OF MEDICAL SCIENCES” payable at Bhuj for Hostel fees Rs. 30,000/- 1st
term and refundable security deposit Rs. 10,000 at the time of joining.
 Hostel room shall be allotted only after fulfilling all formalities and payment of fees as
well as security deposit.
Following documents to be submitted in original:
Sr. Particulars
1 Admission Order
2 Original Document Submission to ACPPGMC Receipt
3 Fee Receipt
4 Free Fee Receipt Card (For Reserve Category-if Applicable)
5 4 Passport Size Photographs

Self-Attested copies of following documents [2 sets]:

Sr. Particulars
1 10th Mark sheet
2 12th Mark sheet
3 School Leaving Certificate
4 MBBS Degree Certificate
5 MBBS Mark sheet [Ist, IInd, IIIrd Part I and II]
6 MBBS Passing Certificate
7 12 Months Internship Completion Certificate
8 Migration Certificate
9 Attempt Certificate
10 NEET PG Mark sheet
11 Provisional / Permanent registration of Gujarat Medical Council/ MCI
12 Cast Certificate in case of SC/ST/SEBC Candidate
13 Non- Creamy Layer Certificate for SEBC candidate.
14 Physical Disability Certificate(Only for PH Category Students)
15 Address Proof (Copy of: Passport, Electricity Bill, BSNL Landline Bill, DL)
16 AADHAR CARD
17 PAN CARD
18 Cancelled Cheque
19 EWS Certificate
20 Copy of Declaration / Undertaking for fees submitted to admission committee
21 COVID-19 Double Vaccination Certificate

For more details, contact: Mr. Indrajit Bhatt – 9726430732

For Hostel Accommodation details, contact: Mr. Dharmesh Panchal – 9099991404
 Student’s Information Form – PG
Note: Please Fill Form in Capital Letters only

PG Course Name : _________________ Date of Admission: _________________

State Quota Mgmt Quota NRI Quota University Quota

Student’s Name : _________________ _____________________ _________________

Recent
SURNAME FIRST NAME FATHER'S NAME Passport size
Father’s Name : _________________ _____________________ ___________________ Photograph

Mother’s Name : _________________ _____________________ ___________________

Permanent Address: __________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

District : _________________________ Pin Code : _______________________________

Email Address : _________________________________________________________________________

Residence Phone : ______________________ Self Mobile : ____________________________

Father’s Occupation: _____________________ Father’s Mobile : ____________________________

Mother’s Occupation: ____________________ Mother’s Mobile : ___________________________

Date of Birth : ____________________ Gender : ___________________________

Blood Group : ____________________ Cast Category : ___________________________

Admission Category : Open / EWS / SEBC / SC / ST / PH / Other

Council Registration No. UG : _______________________________________________________

Name of the Council registered with : ________________________________________________________
Percentile Score of NEET PG : ______________________________________________________
All India Rank : ________________________ State Merit No : __________________________
Category Merit : ________________________ University Merit : __________________________

For Office Use Only

Hostel Facility : _____________ (Yes) / (No) Hostel Charges: __________________________
Payment Mode : DD / Cheque / Online Allotted Room no : _____________________
Reported to Institute on : ______________________________
Executive Name : _________________________ Sign & Date: _____________________
 Hostel Request Form
Date:
To,
The Dean
Gujarat Adani Institute of Medical Sciences
Bhuj, Kachchh, Gujarat Recent

Passport size
Subject: Application for Hostel Accommodation
Photograph
Sir,

I hereby request you to provide me an accommodation in the Hostel for the duration of my studies at
this college.
Student’s Name : ____________________ ______________________ ______________________
SURNAME FIRST NAME FATHER'S NAME
Basic Profile

Father’s Name : ____________________ ______________________ ______________________

Mother’s Name : ____________________ ______________________ ______________________

Gender : Male / Female Marital Status: Married / Single

Date of Birth : _____/_____/_________ Blood Group: ____________________

Address : ______________________________________________________________

______________________________________________________________

City : ____________________ Pin code: _____________________________

Email Address : _______________________________________________________________

Residence Phone : _________________________ Self Mobile: ___________________________

Father’s Mobile : _________________________ Mother’s Mobile: ________________________

Father’s Occupation: _________________________ Mother’s Occupation: ____________________

Local Guardian Name: ______________________________________________________________

Local Guardian Contact: ____________________________________________________________

Admission Details

PG Course : ___________________ Date of Admission: _____/_____/__________

Govt. Quota Univ. Quota Mgmt. Quota NRI Quota

Category : Open / EWS / SEBC / SC / ST / PH / Other

AIQ Rank : _________________ ACPC Merit No. _______________________

NEET Marks : _________________

Financial Details

Hostel & Room No. : ______________ Type of Accommodation: __________________

Hostel Charges; _________________P.A. Security Deposit: __________________________

Cheque / DD No: _____________________ Cheque / DD No: _______________________

Dated: ____/____/_____________ Dated: ____/____/_____________

Bank: ___________________________ Bank: ___________________________

Declaration

l hereby declare that the information furnished is true to the best of my knowledge and solemnly
undertake (promise) that I will strictly follow the rules and regulations of the hostel (copy attached),
which are enforced from time to time and shall not involve in any ragging / strike / demonstration /
unlawful activities throughout my studies in this Institute. If I am found involved in any such above
said activities, I am fully aware that I will be expelled from the college and hostel with immediate
effect.

Date: Signature of the student

I fully agree with the declaration and undertaking given by my ward and I assure that my ward will
adhere to all the rules and regulations of the hostel and undertaking given by him/her. I understand
any violation / indiscipline may attract fine, expulsion, or both to my ward. I solemnly declare that the
above details are true to the best of my knowledge and belief.

Date: Signature of Parent / Guardian

For Office Use Only

Reported for Hostel : ______________________ Hostel Block : ______________________

Room No. : _________________ Room Type : ______________________

Sign of Admin: ____________________________ Sign of Warden: ___________________

 PG HOSTEL ROOM ALLOTMENT FORM

Name of PG Student: _________________________________________________________

Batch: _________________ Hostel Block: ____________________

Room Type: ________________ Hostel Room No: ________________

Furniture and Fixtures provided in the Room:

Sr. No. Description Number Common Area

1. Bed ⓪ ① ② ③
2. Table ⓪ ① ② ③
3. Chair ⓪ ① ② ③
4. Cupboard ⓪ ① ② ③
5. Fan ⓪ ① ② ③
6. Tube Light ⓪ ① ② ③
7. Night Lamp ⓪ ① ② ③
8. Outside Lamp ⓪ ① ② ③
9. Curtains ⓪ ① ② ③
10. Geyser ⓪ ① ② ③

Note: Common facilities available as Water Cooler, R.O. Plant, etc.

Declaration:

I have verified the Number of Furniture and Fixtures indicated above and have found them
to be true. I agree that if the above listed items are found to be damaged or missing then an
appropriate penalty amount may be deducted from my security deposit.

Date: ____ /_____ / __________ Signature of Student: _________________

For Office Use Only

Admin Executive Name : _________________________Sign & Date : _____________________

Warden Name: _____________________________ Sign & Date: _____________________

 PG Resident Undertaking
(Duly notarized on Rs. 300 Stamp Paper)
I, _________________________(s/o)/ (d/o) ____________________________ Age: __________, resident
____________________________________________________________________ enrolled / admitted
for ____________________________ program /course, hereby solemnly undertake that,
1. I have completely read and understood the institute’s fees policy and undertake to
abide by its rules and regulations.
1.1 I undertake to deposit the tuition fees, hostel fees, late fees if any, as per fees
policy and any other fees in time as notified from time to time.
1.2 I also understand that I shall have to deposit late fees due to late payment of
tuition fees and/or hostel fees.
1.3 I also understand that tuition fees, hostel fees and late fees shall not be waived
under any circumstances.
2. I have completely read and understood the institute’s hostel policy and undertake
to abide by its rules and regulations and shall submit separate undertaking at the
time of for availing hostel accommodation. Hostel accommodation and campus
residence is mandatory for all senior and junior Resident as per MCI regulation.
3. I will not indulge in any form of RAGGING (as per UGC/MCI regulations) and I along
with my parents shall submit the online undertaking accordingly on UGC website
and copies of both undertakings will be attached along with this undertaking.
4. I undertake that I shall not participate in any kind of strike or any kind of
uninstitutional activity.
5. I have completely read and understood the institute’s PG leave policy and undertake
to abide by its rules and regulations.
5.1 I shall do Biometric punching while entering and leaving workplace for
attendance,
5.2 I shall avail and submit Casual Leave & Academic Leave on prior approval of
HOD and Additional Medical Superintendent.
5.3 I shall submit copy of approved leaves regularly on or before 26th of each
month to HR dept. for processing of stipend.
5.4 If the above said copy of approved leave is not submitted in prescribed time
limit then it will be consider as Leave without Pay (LWP).
5.5 The leave will be sanctioned/ rejected depending on the work exigencies
without assigning any reason at the sole discretion of the Head of the
Department/ ADMS.
6. If period of leave/LWP/absence is extended beyond permitted duration, I
understand that my period of training shall be extended proportionately.
7. I undertake to enroll myself for the online research methodology course in time and
shall complete the course by the end of second semester as notified by MCI, New
Delhi.
6.1 I shall submit the online certificate generated on successful completion of the
course (Online examination also) in time.
6.2 I undertake to submit my research proposal with due approvals from scientific
committee and ethics committee before end of 1st term i.e., by end of 1st July
2022 for timely submission to university.
6.3 I understand that if I fail to comply with the above regulatory requirement
specified by Medical Council of India, New Delhi I shall not be allowed to
appear in the final examination of the postgraduate course in which I am
enrolled i.e. __________________________________.
 8. I shall submit all regulatory documents such as Original merit documents, GMC
Registration, Online Research Methodology Completion Certificate, Research
Publication, Conference Attendance Certificate etc. to the Academic Department.
9. I undertake to follow the regulations for residency programme framed and as
amended from time to time by the Government of Gujarat & MCI.
10. I will submit the Migration Certificate from my previous university to K S K V
Kachchh University within 02 Months i.e., on or before 01st April 2022.
11. I shall submit medical fitness certificate issued by the competent authority along
with this undertaking.
12. In case I am found to be guilty of any misconduct then I will abide by the decision
taken by the disciplinary committee/ institutional administration.

Name of Resident:

Signature:

Date:

Name of Department: