Price

:

Rs. 500/- For general (including prospectus) Rs. 400/- For SC/ST (including prospectus)

Session : January, 2008

Form No.___________

POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH 160012
Application form for______________________________Course Speciality Applied for__________________________________ Application form duly completed should reach the office of the REGISTRAR by 29-10-2007 ROLL NO.

(TO BE ASSIGNED BY OFFICE) IMPORTANT NOTE : BEFORE FILLING UP THIS APPLICATION FORM PLEASE READ THE ADMISSION NOTICE AND THE PROSPECTUS SUPPLIED WITH THIS FORM CAREFULLY

REGISTRAR Postgraduate Institute of Medical Education & Research, Chandigarh - 160 012 Sir, I submit my application for admission to the course ticked (3) below MD/MS DM/M.Ch. MHA House Job (Dentistry) Please paste here a passport size coloured photograph attested by the Gazetted Officer

Subject:______________________________________________________ a) For Sponsored & foreign MD/MS candidates, mention one subject for which they have been sponsored. b) For DM/M.Ch._________________________________________ (The candidates are required to submit separate application for each subject they want to apply for) I am an applicant under the category ticked (3) below :1. 2. 3. 4. 5. 6. 7. General Sch. Caste Sch. Tribe Rural Area Service Orthopaedic Physically Handicapped (Column No. 2, 3, 4, 5 are not applicable to DM/M.Ch. courses) Sponsored / Deputed______________________________ (Also mention subject) Freign National__________________________________ (Also mentin subject)

FOR OFFICE USE ONLY

Dy. No._______________ Date_________________
(To be filled only by the candidates who download the form website) Bank Draft/Postal order No...................... Date of issue............................................. Name of the issuing Bank........................ Amount Rs................................ Yours faithfully,

c)

Note : The change of category at any stage will not be permitted

(Signature of the Candidate) (________________________) Name in Block Letters)

Place__________________________ Dated_________________________

1

The application form and the acknowledgement card must be completed in the candidate's own handwriting using ball point pen. An application which is incomplete or wrongly filled in, will be rejected. 1. (a) (b) 2. 3. (i) Name in full ( In block letters) (In English) In Hindi (Devnagri Script) : : : : : : : : : : : : ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ : : ___________________________________ ___________________________________ ___________________________________ ____________________________________ ____________________________________ No. _________________________________ : ____________________________________ ____________________________________ : : : : : : : : ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________

Date of birth (as recorded in matriculation or its equivalent certificate according to Christian Era) (a) (b) (ii) (a) (b) Father's Name ( In English) In Hindi (Devnagri script) Mother's Name (In English) In Hindi (Devnagri Script)

4. 5.

Father's occupation and annual income (a) (b) Do you belong to Scheduled Caste/Tribe If yes, state your caste and religion (attach proof)

6. 7.

Sex : Married or unmarried (if married, wife/husband name & occupation)

8. 9. 10.

Nationality State/Union Territory to which you belong

Address in block letters (a) Where interview/selection letter etc. should be sent: (b) Permanent Home Address (c) Telegraph address (if any)
(d) Telephone No. (Mobile Phone) STD Code_______

: :
:

(e) e-mail address (if any) 11. Permanent Medical Registration number and the state in which registered.

12. Are you doing/have done MD/MS ? 12A. Are you employed If yes, give the following details (a) Date of joining (b) (c) (d) (e) (f) Nature of job Name of the Institution/Hospital Govt./ Semi Govt./ Pvt. Designation Pay Scale Name of employer

Note : If you are doing /have done MD/MS, you are not eligible for applying for MD/MS course. Please refer to the point ‘ of General Information of the prospectus. d’

2

13.

Details of MBBS/BDS/MD/MS Examination (a) A failure in the examination, compartment or re-appear in one or more subjects will constitute an attempt. (b) The attempts made at passing the examinations should be mentioned as "FIRST" i.e. No failure/ No compartment/No re-appear). " SECOND" (i.e. one failure/compartment/re-appear etc.) and not as "ONE" or TWO” etc.)
Name of University/ Institute Month & Year in which passed Attempts at which passed Proof at encl. No.

Examiantion Passed

First Professional Second Professional Third Professional Final Professional Percentage of marks obtained in the final_____________________________________MBBS/BDS examination. 13. (b) Details of internship or compulsory rotatory house job. Name of Hospital From To Yr. Month Days Date of Completion Proof at Encl.No.

13.

(C)

Postgraduate examination passed
Name of the college from which the candidate passed MD/MS A. Name of Univerity / Institution B.Month & Year in which passed whether the MD/MS is recognised by MCI, If yes enclosed proof Whether college/ Institution is recognised by MCI if yes enclosed proof Attempts at which passed Proof at Encl. No.

Name of examination passed and the subject

3

14 Have you worked / are working/or doing private practice in rural area for a period of two years or more ? If so, give details : Name of Hospital Place Capacity in which Worked Pay scale From Period To Yr Proof at encl. No.

Month

Days

15.

Give names and complete addresses : of two referees not related to you

1.

_______________________________________ _______________________________________ _______________________________________

2.

_______________________________________ _______________________________________ _______________________________________

16.

Have you any contact persons/guardian in Chandigarh. If so, mention his/her address Telephone No., if any.

_______________________________________ _______________________________________ _______________________________________

17.

Are you being sponsored/deputed by your employer? If sponsored, the application must be accompanied with sponsorhsip, deputation certificate in the form printed at page 7.

_______________________________________

Date____________________ Place___________________

(______________________________________) Signature of the applicant

NOTE : PLEASE DO NOT LEAVE ANY COLUMN UNFILLED / BLANK

4

ATTEMPT

CERTIFICATES

The application must accompany the undermentioned certificates duly signed by the Principal or Medical College/Institute from where the candidates has passed his/her MBBS/MD/MS/BDS Examination. NB : 1. The failure of candidate in any professional MBBS/BDS examination or his/her having been placed in compartment or re-appear in one or more subjects shall constitute as an attempt. 2. The entries under the headng “column” at which passed should be indicated as “FIRST” (i.e. no failure/ Compartment/re-appear), “second” (i.e. one failure/compartment/re-appear) etc. and not as “one”, “two” etc. 3. No other certificate than the one conforming to the under-mentioned format will be accepted.

ATTEMPT

CERTIFICATE - I

Certified that Dr._______________________________________________________________________ son/daughter of Sh.____________________________________________________________________________ has passed professional examination of the MBBS/BDS course as per detail given below :-Examination passed Attempted at which passed 1. 2. 3. 4. First professional Second professional Third professional _____________________________________ _____________________________________ _____________________________________

Final professional _____________________________________ It is also certified that MBBS/BDS degree of this medical/dental college is recognized by the Medical Council/ Dental Council of India. It is certified that _________________________________________commenced his/her rotatory compulsory internship training on __________________ and is due to complete the same on ________________

OR
It is certified that ______________________________________has completed his/her compulsory rotatory internship on __________________________ Session :_________________________ Signature___________________________
Designation __________________________ (Official Seal)

ATTEMPT CERTIFICATE - II
Certified that Dr.________________________________son/daughter of Sh._________________________ has passed the MD/MS examination from the Institute/University in the subject of ____________________________ in the_________________attempt(s) It is certified that the abovesaid MD/MS degree of the institute/University is recognised by Medical Council of India. It is further certified that the degree of M.D./M.S. of College/Institution in the subject of_______________ awarded to him/her is recognised by the Medical Council of India as per their letter No.__________________. A photocopy of the same is enclosed. Station ___________________ Dated____________________ Signature_________________ Designation_______________ Official Seal______________

Note :

1. Deletion/alteration of any word in the above certifcate will lead to rejection of the application summarily and no intimation will be sent to the candidate. 2. In case a photocopy of the letter from the Medical Council of the India Post Graduate Degree College/ Institution is not enclosed, the application will not be considered.

5

DECLARATION BY

CANDIDATE

I hereby declare that the application has been filled in my own handwriting and all statements made in it are true, complete, and correct to the best of my knowledge and belief and nothing has been concealed. In the event of any statement being found false or incorrect or any ineligibility being detected before or after the selection, action such as removal of my name from the rolls and/or any other action as may be considered necessary can be taken against me. 2. 3. I also declare that I have carefully read the contents of the Prospectus in respect of the course applied for by me and undertake to abide by the provision contained therein. I further declare that I fulfil all the eligibility conditions regarding educational qualification, experience etc. prescribed by the Institutte for admission to the course applied for by me. If selected : a) I agree to work on whole time basis : b) c) I shall not engage myself in private practice or part time job during the period. I shall not draw any pay, fellowship or any kind of monetary assistance from any other sources, if I am allowed emoluments by the Institute.

4.

Place ___________________ Date____________________

(____________________________________) Signature of the applicant

DECLARATION BY THE FATHER/GUARDIAN OF THE APPLICANT
I hereby declare that I shall be responsible for timely payment of all dues payable to the Postgraduate institute of medical Education & Research, Chandigarh in respect of my son/daughter/ward (name_____________________________ _________________________) during the period of his/her stay at the Institute and there after until the dues are cleared.

Address_______________________________ _________________________________________

( Signature Relationship to the applicant

)

ENDORSEMENT
No...................................

BY THE EMPLOYER, IF THE APPLICANT IS IN SERVICE
Date.....................................

Forwarded to the REGISTRAR, Postgraduate Institute of Medical Education & Research, Chandigarh for consideration. The undersigned has no objection to the applicant of Dr.__________________________________being considered by the Institute for the course applied for by him/her and if selected, he/she will be relieved within, the prescribed time limit. The applicant is “sponspored/deputed or not sponsored/deputed by us and the sponsorship/ deputation-certificate is enclosed.

Address ____________________________________ ___________________________________________

Signature of the employer with official seal

*Strike out whichever is not applicable

6

RURAL AREA SERVICE CERTIFICATE
Certified that Dr.___________________________________________________________ son/daugther of Shri__________________________________Registration No.___________________has served or carried on private practice in the following place(s) during the period indicated against each :

Place
From

Period
To

Certificate that the above mentioned place comprises a village or a Primary Health Centre of a town with population of less than 5000 and without a municipal area. Date___________________ Station_________________ Signature of the Distt. Magistrate With Seal

SPONSORSHIP CERTIFICATE (Applicable only in case of candidates who are sponsored/deputed) Note : Sponsorship from Private Hospital/Institute/Nursing homes, etc. is not accepted.
Certified that Dr.__________________________________________________________son/daughter of Shri_________________________________is a permanent / regular employee of the Govt. Deptt./Medical College since_________________(Date) and has THREE YEARS of Regular/Permanent Service. Please tick (3) the type of Institution/department sponsoring/deputing the candidate viz.
1. 2. 1. Central Govt. 2. State Govt. 3. Autonomous Body of Central Govt. 4. Autonomous Body of State Govt. 5. Public Undertaking 6. Medical College/Hospital affiliated to a University and recognised by Medical Council of India. Certified that if selected for the course applied for by the applicant he/she will be suitably employed by us after the completion of his/her training course to work for atleast five years in the speciality in which the training is received by him/her at PGI, Chandigarh Certified that no financial implication in the form of emoluments/stipend etc. will devolve upon PGI, Chandigarh during the entire period of applicant’ course. Such payment will be the responsibility of sponsoring/deputing s authority.

3.

Date____________________ Station__________________
NB.1 2. 3. (a) (b) (c) (d) (e)

Signature of the sponsoring/ deputing authority with seal

Deputation/Sponsorship of candidates holding tenure appointments (like House Job or Junior or Senior or Senior Residency), adhoc or contract or honorary or appointment against a leave vacancy shall not be accepted. The sponsoring/deputing institution should not nominate more than one candidate for a speciality./super speciality. The candidate must indicate the subject of their choice in the application clearly as page 1. Sponsoring/deputation of candidates will be accepted only from the following : Central Govt. Departments/Institution State Govt. Departments/Institution Autonomous bodies of the Central or State Govt. Public Sector Undertakings Medical Colleges affiliated to a University and recognized by the Medical Council/Dental Council of India.

In case of candidates deputed/sponsored by Medical Colleges affiliated to a University and recognized by the Medical Council of India, the deputation/sponsorship certificate signed by the Principal of the Medical College concerned only shall be accepted.

Note : The three photographs to be pasted on this form at the place indicated must be identical. The photograph should be signed by the candidate in ink on the front.

7

Essential documents which must accompany the applications : Documents 1. 2. 3. 4. 5. 6. 7. 8 9. 10. 11. Attested copy of Matriculation/Higher Secondary Certificate showing date of birth. Attested copy of certificate of passing MBBS/BDS examination Attested copy of certificate of passing MD/MS examination Internship completion certificate Attempt certificate I and II in the forms appended to the application form. No other certificate is entertained. Attested copy of certificate of the character and conduct from the Institution last attended. Attested copy of certificate of permanent Registration with central / State Medical Registration Council/Dental Council of India Attested copy of Caste Certificate in Hindi/English Script Enclosure No.

____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ ____________________________

Sponsorship/deputation certificate in the prescribed form, if applicable. ____________________________ Acknowledgement card with postage stamp of Rs. 5/- affixed thereon. ___________________________ Three self addressed envelopes of size 10 x 23 cms. Rs. 5/- postage stamp on each envelop for use by this office for sending interview letters, etc. Rural Area Certificate attested by Distt. Magistrate Orthopaedically handicape certificate (if applicable) ___________________________

12. 13.

____________________________ _____________________________

IMPORTANT

NOTE

In case any candidate is found to have supplied false information or certificate etc. or is found to have concealed or withheld some information in his/ her application form, He/She shall be debarred from admission. Any other action that may be considered appropriate by the Director of the Institute may also be taken against Him/Her which may include criminal prosecution.
Dated_____________________________ Place _____________________________ No. of Enclosures :__________ Signature of the Candidate

8

POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH
APPLICATION FORM FOR THE ADMISSION IN MD/MS,DM/M.Ch., MHA House Job (Dentistry) COURSES SESSION : (Form for the Computer) INSTRUCTIONS 1. Please read the Information given in the prospectus carefully before filling up this Application Form. 2. This application form should reach on or before Serial No. Roll No. JANUARY, 2008

29-10-2007
(To be filled in by the Office)

3. Use only BLUE/BLACK ink to fill in BLOCK/CAPITAL LETTERS. CANDIDATE’S NAME

FATHER’S NAME

MOTHER’S NAME

ADDRESS FOR COMMUNICATION (Please do not repeat your name and father’s name)

Ct iy

Pin Code

DATE OF BIRTH

NATIONALITY 1=Indian 2=Foreign Year COURSE
1-MD/MS 2-DM/M.Ch 3-MDS 4-House Job (Oral Health Sciences)

SEX 1=Male 2=Female

Day

Month

CATEGORY
A. B. C. D. E. F. G. General Scheduled Caste Rural Area Services Sponsored/Deputed Scheduled Tribes Foreign/National Orthopaedic Physically Handicapped

For DM or Mch Course, mention Super Specality Code as given overleaf

For Category D, F&G mention name of the subject

%age Marks in MBBS/BDS

.

MBBS/BDS

MD/MS

Date of Completion of Internship

Employed 1=yes 2=No

%
(Enter Max. attempts taken in any of MBBS/BDS, MD/MS exam.) Day Month Year

DECLARATION
I have carefully read the Instructions given in the prospectus. I hereby solemnly and sincerely affirm that the Statement made and information furnished by me with application form are true and correct. If, however, it is found that any information furnished herein is fraudulent, incorrect or untrue in material particulars, I realise that I am liable to criminal prosecution and my selection and admission to the course is liable to be cancelled.
Date Signature of Candidate

List of Super Specialities for DM/M.Ch Courses Code 01 02 03 04 05 06 07 Super Speciality Cardiology Clinical Pharmacology Endocrinology Gastroenterology Nephrology Neurology Neonatology Code 08 09 10 11 12 13 Super Speciality Pulmonary & Critical Care Medicine Cardiovascular & Thoracic Surgery Neurosurgery Paediatric Surgery Plastic Surgery Urology

POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH 160012
SELECTION OF CANDIDATE FOR MD/MS, DM/M, CH., MHA, HOUSE JOB (DENTISTRY) COURSES

Category_____________________
1.

Candidate's Attendance Sheet

SESSION :JANUARY, 2008

Roll No________________________________ (to be assigned by Office) Examination Centre : Chandigarh Specimen signature of the candidate__________________________

2. 3.

Please paste here a passport size coloured photograph attested by the Gazetted Officer

....................................................................................................................................................... Nothing to be written below this line by candidate ....................................................................................................................................................... ATTENDANCE SHEET ....................................................................................................................................................... Date and Time Signature of candidates Signature of Invigilator (to be signed in Examination Hall) ....................................................................................................................................................... _________________ ________________________________ _________________ ________________________________ _________________ ________________________________ __________________ __________________ __________________

POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH 160012
SELECTION OF CANDIDATE FOR MD/MS, DM/M, CH., MHA, HOUSE JOB (DENTISTRY) COURSES

Category_______________________
1.

ADMIT CARD

SESSION : JANUARY, 2008

Roll No.___________________________ (to be assigned by Office)

2. 3.

Please paste here a passport size coloured photograph Examination Centre : Chandigarh attested by the Specimen signature of the candidate___________________________ Gazetted Officer

Please admit Dr._______________________________________________whose photograph along with the specimen signature are affixed thereon to the selection test for MD/MS, DM/M.Ch.,MHA., House Job (Dentistry) mentioned above.
REGISTRAR Postgraduate Institute of Medical Education & Research, Chandigarh.