Application Form :

500

Mahatma Gandhi University of Medical

Sciences & Technology, Jaipur
RIICO Institutional Area, Sitapura, Tonk Road, Jaipur - 302 022
Phone : +91-0141-2770798, 2771777, 2771001-3
website : www.mgumst.org

Application Form for Admission to

Master of Occupational Therapy (MOT) Course - Session 2014 - 15
(Application Form to be filled legibly and correctly in capital letters by the candidate)

Application Form No.

To be filled in by University
Received Rs. 500/- vide receipt No.............................
Dated...............
Cashier

1.

To be filled by the Institution

Name of the Candidate (as given in Class X Certificate)

First Name :
Surname :

Photograph
of the
candidate

Contact No.
E-mail ID
Father's Name:
Mother's Name :
2.

Address :

Signature

PIN Code
Tel. No. (R)

Mobile No.
(Telephone Number with STD code)
( Day )

3.

( Month )

( Year )
4. Nationality : _____________________

Date of Birth
Place of Birth :

5.

Gender : Male

6.

Category: General

State

Country

Female
SC

ST

OBC

SBC

:: 2 ::
S.
No.

Exam
Passed

Name of
Name of
Max. Marks Percentage
Year Board/University School/College Subjects
Remarks
Marks Obtained of Marks

1. 10th
2. 12th
3.
7.

Graduation
(BOT)

In case of downloaded admission form, a Demand Draft of Rs. 500/- is to be enclosed in favour of Mahatma Gandhi
University of Medical Sciences & Technology payable at Jaipur or cash of Rs. 500/- be paid at the cash counter of the
University, before submission of the admission form.

List of enclosures
(1)
(2)
(3)
(4)

Self attested photocopy of class 10th Certificate.

Self attested photocopy of the mark-sheet of 10+2 examination .
Self attested photocopy of the mark-sheet of qualifying examination - B.Sc. (OT) or BOT or equivalent.
Caste Certificate for Reservation Category (OBC/ST/SC/SBC etc.) to be attached if category is other than General
Category.
(5) Physically Handicapped Certificate
(6) TC from the Institution last attended.
(7) Migration Certificate .
(8) Character Certificate from the Principal of the Institution last attended as per the format attached.
(9) Declaration (General Undertaking) from Candidate on a Non-Judicial stamp paper of Rs. 10/- duly attested by the Notary
Public as per the format attached (Declaration-1).
(10) Declaration (General Undertaking) from Parent / Guardian on a Non-Judicial stamp paper of Rs. 10/- duly attested by the
Notary Public as per the format attached (Declaration-2).
(11) Affidavit of Anti Ragging by the candidate on a Non-Judicial stamp paper of Rs. 10/- duly attested by the Notary Public as
per the format attached (Undertaking-1).
(12) Affidavit of Anti Ragging by the Parent / Guardian on a Non-Judicial stamp paper of Rs. 10/- duly attested by the Notary
Public as per the format attached (Undertaking-2).
Please Tick ( ) the documents you have annexed.

I declare that all the information furnished by me in the application form is true to the best of my
knowledge. If any information found false, my application may be rejected. I will submit my original
Marks-sheets, Caste Certificate, T.C., Migration Certificate, Character Certificate before my
admission.
Place ______________
Date _____________

Signature of the applicant

Note : Duly filled in application form must reach by post or must be submitted in person in the office of the Registrar, Mahatma Gandhi
University of Medical Sciences & Technology, Sitapura, Tonk Road, Jaipur - 302 022 on or before the notified last date of
submission ofAdmissionApplication Form.
Downloaded Application Form shall not be accepted without fee of Rs. 500/- Cash/DD. Incomplete application forms or the forms
received after the last date because of postal delay or any other reason shall not be accepted.
For future correspondence please quote yourApplication Form number.

CHARACTER CERTIFICATE
From the Institution attended last
It is to certify that_____________________________________________________
S/o / D/o ________________________________________________________ who has studied in
this Institution from _______________________ to ________________________ bears a good
moral character. His/her behaviour was good with teachers and students. He/she has neither
displayed persistent violence of or aggressive behaviour nor any desire to harm others.

Name of Institution last attended : __________________________________

Signature of
Head of the Institution
with Seal
Date :___________

Declaration-1

Format for the Declaration to be filled and signed by the

Candidate on a Non-Judicial Stamp paper of Rs. 10/- duly
attested by the Notary Public
I ............................................................... son / daughter of...............................................................
age ..................... sex ..................... resident of ........................................................ solemnly affirm :
1.

That the statement and information furnished by me in the application form for
admission to ________________________________________course (Name of the
Course) for the academic year 2014 - 2015 and the enclosures submitted with the
application form are true to the best of my knowledge and belief. I realize that if any
information furnished here-in is found to be untrue in the material particulars, I shall be
liable to criminal prosecution as well as to forgo my admission to the course as well as
removal from the College.

2.

I have not been debarred from appearing at any examination held by any University /
Board / School or College.

3.

I also undertake to pay the College and other dues regularly.

4.

I hereby agree to confirm and abide by all rules, acts and laws at present in force in the
college and as fully explained in the prospectus or those that may thereafter be made for
the administration of the college and enforced by the Institution or the University from
time to time. I do declare that I will not indulge in any act of Ragging inside or outside
the College campus which may result in disciplinary action against me.

5.

I also declare that :

(a) I have not been convicted of any criminal offence nor have I been released on bail
in connection with a criminal case.
(b) No case of criminal offence or moral turpitude is pending against me in any Court
of Law.
(c) No complaint or F.I.R. has been lodged against me by the University / Principal of
a Constituent College / School.
(d) I have not resorted to any act of indiscipline during the past years.

6.

I fully understand that the Principal of the College / Disciplinary Committee shall have
the full liberty to expel / rusticate me from the College for any infringement of the Rules
of Conduct and Discipline prescribed by the College/ University.

Place :___________
Date :___________

Signature of the Candidate

Declaration-2

Format of the Declaration to be filled and signed by the

Parent / Guardian of the Applicant on a Non-Judicial Stamp
paper of Rs. 10/- duly attested by the Notary Public

I ............................................................. Parent / Guardian of............................................................

age ..................... sex ..................... resident of .................................................................. solemnly
affirm and declare :
1.

That the particulars furnished by my son / daughter / ward in this application form are
correct to the best of my knowledge and belief.

2.

I undertake and bind myself to pay on behalf of my son / daughter / ward such fees,
charges, etc., which the Institution may levy from time to time by due date and in the
event of failure on any part of my son / daughter / ward, the Principal / Disciplinary
committee of the College may take such action against my son / daughter / ward as may
be deemed proper.

3.

I do hereby also agree and confirm that my son / daughter / ward would abide by the
rules, Acts and laws fully explained in the Prospectus and those enforced by the
institution from time to time, and ensure that my son / daughter / ward will not indulge
in any inside or outside the College campus activities which may result in disciplinary
action against him / her neither inside nor outside the College / University campus.

Place :___________

Date :___________

Signature of the Parent / Guardian

Undertaking-1

UNDERTAKING BY THE CANDIDATE

Format for the Affidavit to be filled and signed by the Candidates on a Non Judicial
Stamp Paper of Rs. 10/- duly attested by the Notary Public.
CANDIDATES AFFIDAVIT
I, ________________________________________son /daughter of Shri __________________________
aged ________ resident of _______________________________ hereby state that :
1.

I have taken admission in _______________________________________________(name of course).

2.

I have carefully gone through the explanation and punishments related to ragging defined in Petition No.
646/ 98 (Vishva Jagriti v/s Central Government episode) of Supreme Court, New Delhi and I have also
made my parents aware of it.

3.

I know that the Supreme Court has banned ragging in educational institutions.

4.

I will not participate in any ragging activity during the tenure of the course.

5.

In case I am found involved in any ragging activity, I shall be liable to punishment as per the relevant
Regulations and theAct of the Central / State Government.

Date : ____________
Place : ___________

DEPONENT

VERIFICATION
I ___________________________________ son/ daughter of Shri _______________________ aged
__________ resident of ______________________ hereby declare that the facts mentioned above from point
number 1 to 5 are true and correct to the best of my understanding, knowledge and belief. So help me God.
DEPONENT
Date : _______________

Address: ______________________________
______________________________
______________________________

(Verification by the Notary Public)

Undertaking-2

UNDERTAKING BY PARENT / GUARDIAN

Format of the Affidavit to be filled and signed by the Guardian/ Parents on Non-Judicial
Stamp paper of Rs. 10/- duly attested by the Notary Public.
PARENT'S/GUARDIAN'S AFFIDAVIT
I, _______________________________________________ son of Shri ______________________________
aged ________ resident of _______________________________ hereby state that :

1.

My son/daughter _________________ has taken admission in _______________________________

__________________________ (name of course).

2.

I am aware of the explanation and punishment related to ragging defined in Petition No. 646/98 (Vishva
Jagriti v/s Central Government episode) of Supreme Court, New Delhi.

3.

My son/daughter shall not participate in any ragging during the course.

4.

In case my son/daughter participates or is found involved in any ragging activity he/she shall be liable to
punishment as per the relevant Regulations and theAct of Central / State Government.

Date : ____________
Place : ___________

DEPONENT
VERIFICATION

I ________________________________________ son of Shri ____________________________________

aged __________ resident of ______________________ hereby declare that the facts mentioned above from
point number 1 to 4 are true and correct to the best of my understanding, knowledge and belief. So help me God.
Date : ___________

DEPONENT
Address: ______________________________
______________________________
______________________________

(Verification by the Notary Public)

Mahatma Gandhi University of Medical

Sciences & Technology, Jaipur
RIICO Institutional Area, Sitapura, Tonk Road, Jaipur - 302 022
Phone : +91-0141-2770798, 2771777, 2771001-3

Master of Occupational Therapy (MOT) course

Application Form No.

Session 2014-15

INTERVIEW CALL LETTER

TO_________________
Kindly refer to your application for admission in___________________________ (name of the course) for the
academic year 2014-15. In this regard you are requested to appear for an interview before the Selection
Committee on________________________________ at ___________________________
You are also requested to bring all the relevant original certificates at the time of the interview

Convener (Admissions)

Mahatma Gandhi University of Medical

Sciences & Technology, Jaipur
RIICO Institutional Area, Sitapura, Tonk Road, Jaipur - 302 022
Phone : +91-0141-2770798, 2771777, 2771001-3

Master of Occupational Therapy (MOT) course

Application Form No.

Session 2014-15

ACKNOWLEDGMENT RECEIPT

RECEIVED application on___________________ along with ______________________ No. of copies of

Certificates from Mr./Ms._______________________________________ for_________________________
_________________________________ (name of course)

Receiver
(To be filled and returned with Application Form)