NITTE UNIVERSITY ALL INDIA POST GRADUATE ENTRANCE TEST NUPGET-2012

APPLICATION FORM Preferred Entrance Test Centre (choose one) Course selected Name of the candidate Fathers name Mothers name Spouses name Date of Birth (attach proof) Sex Place of Birth (Write Taluk, District and State) Mother tongue Nationality / Religion Category (General/OBC/SC/ST) College where you have studied MBBS/BDS (give full address) Is the college recognized by the MCI/DCI? Name of University awarding the Degree Percentage of marks from I to IV year Aggregate percentage of marks : (attach photocopies of marks cards) Year I year II year III year IV year I year No. of attempts for each University Exam (To be obtained from the Principal of the College) II year III year IV year
Marks obtained/max.marks

Affix recent Stamp size Photograp

Bangalore/ Delhi / Ernakulam/ Hyderabad / h Kolkata / Mangalore/ Mumbai MD / MS /MDS

Male / Female

Aggregate

.. %

Demand Draft details Postal address (As Test Admission Ticket will be sent to this address, the same should be furnished in the TAT also) Permanent address

No.: Amount:

Date: Bank:

PAN CARD NO: Father: Mother: Self:

Whether employed? If yes, give details of post held, organization, years of experience Is any enquiry pending against you? Are you under suspension?

Phone No.s
Land line (with code): Mobile :
e-mail ID

Yes / No Yes / No Yes / No

Yes / No Are you under unauthorized absence from service elsewhere? Yes / No Whether a spare copy of recent photograph has been enclosed? Registration Number (Indicate Permanent or Provisional and attach copy of Medical Registration Certificate/ Dental Registration Certificate) Name of the State/Central Council where registered
Date of Completion of Internship Is check list enclosed with marking against enclosed items? Any other remarks you wish to make

Yes / No

The above statement made by me is true to the best of my knowledge, information and belief. Signature of the applicant with date

9. Check List: (This should be enclosed with application)

Tick ( ) against item numbers complied with:

i) Copy of SSLC marks card and (or equivalent) for proof of Date of Birth. ii) Copies of Marks cards of all years of the Degree (University Exam Marks Cards) iii) Copy of Attempt Certificate from the Principal of the College. iv) Copy of Degree Certificate / Provisional Degree Certificate v) Copy of Medical Council Registration Certificate/Dental Council Registration Certificate vi) Copy of Internship Completion Certificate vii) Demand Draft for Rs. 2,000/- favoring Nitte University, Mangalore viii) 1 (extra) stamp size photograph (similar to that pasted on the Application & Test Admission Tickets) ix) Test Admission Ticket (in duplicate) having Name with address and Centre name entered and duly signed by the candidate. x) Other documents if any, to be specified

Order of arranging the application form (from the top):

1) DD 2) Test Admission Ticket (Fill all details EXCEPT the TAT No., in duplicate) 3) Check list 4) Photograph 5) Application form 6) Copy of Marks Cards & Certificates

INTERNSHIP COMPLETION CERTIFICATE

TO WHOMSOEVER IT MAY CONCERN

This is to certify that Dr is/was a bonafide student of this Institute from to He/She has completed / is likely to complete his/her compulsory Rotatory Internship on .. This college is recognized by Medical Council of

India /Dental Council of India as per MCI/DCI Order No..dated ..

Date:

Signature of the Principal with College seal