MAHARASHTRA UNIVERSITY OF HEALTH SCIENCES, NASHIK

Application and Preference Form for Admission to Certificate Course in

"Modern Pharmacology" for Registered Homoeopathic Practitioners in the
State of Maharashtra

Application No Please affix

Academic Year : 2019-20 your recent
2019/1335
Photograph

1 Full Name of the Applicant JOSHI SAMIR MUKUNDRAO

2 Address for Correspondence at&post.belora tq.chandur bazar dist.amravati 444704

3 Email ID joshisamir85@gmail.com

4 Mobile No 9881952783

5 Gender Male

6 Date of Birth 27-Feb-1985

7 Nationality INDIAN
If Foreigner, specify Country :

8 Caste & Sub-Caste BRAHMIN /

9 Category OPEN

10 Marital Status MARRIED

11 Physical Handicapped No

12 MCH Registration No 48493

13 Date of Registration No 02-Jun-2009

14 Latest Renewal of Registration From : 01-Jun-2019 To : 01-Jun-2024

15 Whether the registration is Yes

valid on the cut off date for
filling up this application ?

16 Educational Qualification :

Level of Year of Name of Course Name of Board / University

Course Passing

Degree 2007 B.H.M.S Maharashtra University of

Health sciences,Nas

17 Application Fee Detail :

Date Status Transaction ID Reference No Amount

17/07/2019 S 156335105366831 23502447 5000.00

18 College Preference List :

Report Print Date : 17-Jul-2019 Report Print Time : 17:31:15 Page No : Page 1 of 4
 Priority No Name of College

1 Dr. Punjabrao alias Bhausaheb Deshmukh Memorial Medical College, Amravati

2 Government Medical College, Akola

3 Shri. Vasantrao Naik Government Medical College, Yavatmal

4 Government Medical College & Hospital, Nagpur

5 Indira Gandhi Government Medical College, Nagpur

6 Government Medical College, Jalgaon

7 Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha

8 N. K. P. Salve Institute of Medical Sciences & Research Centre & Lata Mangeshkar
Hospital, Nagpur

9 Godavari Foundations Dr. Ulhas Patil Medical College & Hospital, Jalgaon

UNDERTAKING

I hereby declare that above information furnished by me is true and correct to the best of my
knowledge. If any information furnished by me found fraudulent/incorrect/false at a later date, I am aware
that my admission is liable to be cancelled and Civil/Criminal action can be prosecuted against me.

Online Application Submit Date : 17-Jul-2019

Place :

Date : Signature of Applicant

Report Print Date : 17-Jul-2019 Report Print Time : 17:31:15 Page No : Page 2 of 4
 List of documents to be submitted by the candidate
Sr. Document Name Yes No
No

1 Proof for date of Birth

2 a) Diploma Certificate

b) Degree Certificate

c) Post Graduate Degree Certificate

d) Change of Name ( if any)

3 MCH Registration Certificate

4 Caste Certificate ( If Applicable )

5 Caste Validity Certificate ( If Applicable )

6 Physically Handicapped Certificate (If applicable )

7 Non-Creamy layer Certificate (If any)

8 NOC from Maharashtra Council of Homoeopathy (Original)

9 Undertaking as per Annexure-D

10 EWS Certificate (If Applicable)

Note : Document submitted along with Application Form must be self certified by the Applicant

Report Print Date : 17-Jul-2019 Report Print Time : 17:31:15 Page No : Page 3 of 4
 MAHARASHTRA UNIVERSITY OF HEALTH SCIENCES, NASHIK

Payment Receipt

Transaction Date 17-Jul-2019

Activity Detail Application Form Fee for MP Course

Applicant Name SAMIR JOSHI

Email Address joshisamir85@gmail.com

Mobile 9881952783

Application No 2019/1335

Transaction ID 156335105366831

Reference No 23502447

Payment Status S

Online Amount Paid 5000.00

Note : This is computer generated receipt and does not required signature.

Report Print Date : 17-Jul-2019 Report Print Time : 17:31:15 Page No : Page 4 of 4