PK DAS INSTITUTE OF MEDICAL SCIENCES Approved by MCI, India & Affiliated to Kerala University of Health Science (KUHS) Vaniamkulam P.0., Ottapalam, Pin - 679522, Palakkad Dist., Kerala Ph: 0466 2344700, Email :info@pkdims.org, Website : www.pkdims.org PVN ee Application Form No: Year MBBS Please ensure that the application form is complete in all aspects including the signatures of student and paren¥ guardian. As the information given in the application form is Please affix most important for admission please take utmost care selfattested Tick (7) the appropriate box [_] and leave blank where not applicable oy CHOICE OF COURSE CATEGORY MERIT MGMT NRL PERSONAL DATA (IN CAPITAL LETTERS ONLY) Name Sex: MDF Address E-mail Date of Birth Date Month Year Blood Group Nationality Religion Caste Community SCsT sesc __| OFC Bc GENERAL OTHERS Parents Name Father Mother Mob.No, Mob.No E-mail E-mail Profession India Abroad Annual Income z Orus $ Guardian's Name Address E-mail Telephone No. Mob No,Address for Communication House name HouseNo Post Office Pin Place Tel, District Mobile State Fax Country E-mail Details of Qualifying Examination Name Name of the Institution (with place) in which candidate studied for +2 exam Reg. No. Month & Year of passing Marks secured in Physics, Chemistry, Biology & En: 1g examination. Physics () Chemistry (ll) Biology (II) Total (LHI) English Percentage of Marks secured in Physics, Chemistry, Biology & English in the Qualifying examination. Physics (I) Chemistry (tl) Biology (I) Total (L+1l4Il) English Marks secured in Physics, Chemistry and Biology in the Medical Common Entrance Exar Government of Kerala /All India Pre Medical Entrance Examination(AIPMT) n 2015 CEE Paper | (Chemistry & Physics) Paper Il (Biology) Total (III) [ Rank scored in Medical Common Entrance Examination CEE / AIPMT / OTHER TESTS APPROVED BY MCI ‘APPLNO ROLL NO MARKS, RANK Marks secured in Physics, Chemistry and Biology in the Medical Entrance Examination by Private Medical College Management Association (KPMCMA) Paper | (Chemistry &Physics) Paper Il (Biology) Total (l+Il) Rank secured in KPMCMA, Rank No: Hall Ticket No.Fear N ey Please mention any special achievements / publications Year Description Participated Remarks NSS Nec Sports Pama Meat} Language Read Write Speak Mother Tongue Medium of instruction during last three years of study : frags es) Name two contacts to whom we can refer about you Name Designation Address Telephone No. : Fax MobileNo, : E-mail 2. Name Designation Address Telephone No. Fax Mobile No, E-mail Do you require hostel facilities : Yes | Noprey GLU eye Ps seat a I have understood the prospectus, the rules, regulations, course details, recognitions, fees details, examination, board/university details, hostel/mess rules etc. b. I shall secure 90% attendance in all future semesters. | shall pay all my dues in time and shall not claim any refund for any reason whatsoever, | know any fees/ charges/dues/fees/fines paid by me are neither refundable nor transferable. In case | am forced to discontinue for any reason, after paying full/part of admission fee/or any charges to the college, | know that | have to pay the entire fee of the course, for which | have joined, whether | study or discontinue the studies al any time for any reason. 4. I know that | have to pay all my fees/dues/ other charges in time, otherwise | have to pay late fees as fixed by the College, | also know that hostel mess charges applicable are to be paid if | am residing in the College hostel, | have to pay the full hostel rent even if | stay for one day. e. Also know that all original certificates are to be deposited with the college and it will be returned only after the completion of the course and after full payment of the course fees/dues. . Lknow that raging and teasing is a criminal offence; Minimum punishment is dismissal from the college and filing of ELR g. | know that | cannot bring or use Mobile Phone inside the campus. If | do , | know that faculty members, HOD's, Principal, Director and Management representative can seize the Cell Phone and also a fine of Rs.5000/- will be imposed, and the cell phone will not be given back. Further | know that | will be summarily suspended from the college forthwith. h. I will not participate in any political activities, strike,Dharnas, Gheraos, demonstrations in the College campus or Hostel premises nor will | induce others to do so. | will not indulge in any act which may result in damages or losses to the College or Hostel property or its prestige/reputation and will not conduct myself in any manner which will show disrespect to any staff, inmates or Hostel authorities. i. [declare that the statements given above are true and correct. Signature of Parent / Guardian Place Name of Parent / Guardian Signature of Applicant Date OFFICE USE Admission No, Date of admission Check List: 1, SSLC/10"Y Equivalent Certificate "11. Eligibility Certificate fromBoard/University 2. +2 Certificate 12. Attested copies of all certificates 3. Conduct Certificate 13, NRI status certificate (if applicable) 4. Tansfer Certificate 1. Passport copy 5, Medical Fitness Certificate 2. Employment Certificate Certificate issued by a scheduled bank 6. Community Certificate (if applicable) y litappliceble) stating that he/she is a Non-Resident 7, Migration Certificate (if applicable) Indian holding an NRI account 8. Income Certificate (if applicable) 4. Affidavit /declaration by the NRI relative 9. Five passport & Three stamp size photos 5. Relationship Certificate issued by the village officer/revenue authorities. 10. Entrance Rank Certificate Office seal Director / Principal