APPLICATION FORM
Rajiv Gandhi University of Health Sciences, Karnataka
4th 'T' Block, Jayanagar, Bangalore-560 041
Application for the Registration for the Ph.D Degree (Medical) as Full time Scholars in the
Department of Reproductive Biology /Embryology
1. Name in full (in capital letters)
2. Permanent address in full
Telephone No, Fax, e-mail, if any
3. Address for correspondence
Telephone No, Fax, e-mail, if any
4. Sex
5. Nationality
6. Date of Birth (in figures)
7. Details about Under-Graduate and Post-Graduate degrees
Sl. Degree Name of the Year of Subjects Division/ Percentage of
No. College/Institution passing studied Grade Marks
8. Title of the proposed research work/thesis for
Ph.D with a Synopsis of the work to be carried
out (enclose six copies of the Synopsis)
9. College/Institution in which the candidate BACC Healthcare Pvt. Ltd.
proposes to conduct the research work for Ph.D
course
10. Name, Qualifications & Designation of the Dr.Kamini A. Rao, DGO, DORCP, DCh, FRCOG,
Guide, who will be guiding the candidate (UK) MOBG, (UK), FICOG, PGDMLE(Law), FNAMS
Medical Director, BACC Healthcare (P) Ltd.
11. Whether at present candidate is getting any
research fellowship/grant/scholarship
If Yes,
i) Name of the University/Institution
ii) Year of fellowship/Grant
iii) Duration of fellowship/Grant
iv) Source of fellowship/Grant
v) Value of fellowship/Grant & its
tenure
If No,
How will you support yourself
Financially during the Ph.D course?
12. Amount of the Fees paid
[mention Challan/Receipt No. and date]
13. Whether all the documents listed in Annexure –
III enclosed or not
I hereby declare that all statements made in this application are true, complete and
correct to the best of my knowledge and belief. I understand that in the event of any information
being found false or incorrect, my candidature for Ph.D degree is liable to be cancelled by the
University.
Date:
Place: Signature of the candidate
Remarks of the Guide
Signature, Name and Seal of the Guide
Signature, Name and Seal of Signature, Name and Seal of Head
of the Department Dean/Director/Principal of
the College / Institution
List of Documents to be enclosed along with the application form
1. Final Year degree marks
2. Graduate degree Certificate
3. Post-Graduate degree marks card
4. Post-Graduate degree Certificate
5. Consent letter from the guide
6. Notification from the University recognizing the guide and the institution /College
7. Notification from the University recognizing the institution /College
8. No Objection certificate from
a) Head of the department and the institute ,where he /she is employed
b) Head of the department and the institute ,where the candidate intends to pursue
the Ph.D Course
9. Preliminary Synopsis of the proposed thesis – three copies
10. Photograph of the candidate
Note: Attach only attested photocopies of marks card, degree certificate, or of any other document.
Produce the original at the time of Interview.
