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RAJASTHAN UNIVERSITY OF HEALTH SCIENCES, JAIPUR
Form No. Application Form for Pre PG Dental Examination- 2007 For admission to MDS (To be kept in the record of the University) SUMMARY SHEET Enter the Category for which application form is being submitted: In-Service- SC 1 NS General- SC In-Service- ST 2 NS General- ST In-Service- OBC 3 NS General- OBC In-Service- Others 4 NS General- Others (Non–Service) 1. Full Name 5 6 7 8

2. (a) Father’s Name (b) Mother’s Name 3. Date of Birth Date Month Year

4. Telephone Nos.(with STD code)

(R) ……………………………. (O) ………………………… (M)……………………………. (Fax)……………………….

5. Which Category you belong to?

SC/ST/OBC/General

………………….

6. Are you entitled for benefit under Disabled category? 7. Are you entitled under In-Service Category ? 8. Eligibility Category (A/B/C) of Non-Service Candidates Name of Husband for Category C only 9. Date of Completion of Internship Training ………………………………………………………….. 10. Permanent Registration Number with the State Dental Council ……………………........... Note: Incomplete application forms due to any short coming(s) will be rejected automatically. No further communication will be made to the candidates in this regard. …………………………..

Web Copy

Last Date 10–1– 2007

Roll No………………… (Leave Blank)

Price: 250/- (Rs. 300/- if required by post)

RAJASTHAN UNIVERSITY OF HEALTH SCIENCES, JAIPUR
Application Form for Pre-P.G. Dental Examination- 2007 For admission to MDS Courses (To be kept in the record of the University)

Signature of the candidate to be taken in Examination Hall Paper I Paper II

AFFIX YOUR RECENT PHOTOGRAPH Duly signed by the candidate and attested by Principal of his/her Dental college/or DMHS, Jaipur

To be filled in by the candidate D.D.No. ……………….. ….. Date: ______200____amount Rs. 1500/(Rs. 1750/- in case of downloaded forms) Bank………………………………………………………………………. Enter the Category for which application form is being submitted: In-Service- SC 1 NS General- SC In-Service- ST 2 NS General- ST In-Service- OBC 3 NS General- OBC In-Service- Others 4 NS General- Others 1. Full Name 2. (a) Father’s Name (b) Mother’s Name 3. Date of Birth 4. Full Postal Address

5 6 7 8

Category Code

………………………………………………………………………….. ………………………………………………………………………….. ………………………………………………………………………….. ………………………………………………………………………….. ………………………………………………………………………….. ………………………………………………………………………….. City ……………………...………………PIN…………………………

Telephone Nos.(with STD codes)

(R) ……………………………. (O) ………………………… (M)……………………………. (Fax)……………………….

5. State/Union Territory to which you belong …………………………………………………………. 6. Nationality ……………………… 7. Sex ………………………………….

8. Which Category you belong to? SC/ST/OBC/General …………………. (SC/ST/OBC candidates must attach an attested copy of the caste certificate) 9. Are you entitled under In-Service Category ? Yes/No. ………………. (If yes, attach the requisite certificate issued by DMHS, Jaipur) In case of army personnel, certificate to be issued by Chief of Army Dental Services. 10. Eligibility Category (A/B/C) of Non-Service Candidates ………………………….. [See Instruction Booklet for details about A/B/C and attach attested copy of requisite certificates

Category A must specify following details of Final BDS Examination of University of Rajasthan/ Rajasthan University of Health Sciences, Jaipur Roll Number …………………….. Year of Examination ……………….. Category B, must specify details of All India Competitive Examination Name of Examination Conducted by Government Agency Name of College Whether College is recognized by DCI?
Attach the certificate from the Principal of Dental College and attested copy of Bonafide Resident Certificate

Category C, must specify following details Name of Husband Address Date of Marriage
Attach attested copy of the Marriage Certificate and attested copy of Bonafide Resident Certificate of husband

11. Date of Completion of Internship Training ………………………………………………………….. 12. Permanent Registration Number with the State Dental Council …………………….. 13. Academic Qualifications: Details of Marks obtained in BDS Examination.
BDS Name of the University/ Institutions State in Which College/Institution situated Month & Year of Passing Percentage of Marks Obtained Total No. of times appeared in the examination including the one in which passed

Ist BDS 2nd BDS 3rd BDS Final BDS Attach attested copies of the Degree/Provisional Certificate and Mark-sheets related to the BDS Examinations mentioned above. DECLARATION I hereby solemnly and sincerely affirm that the statements made and information furnished by me in the application form and also in the enclosures submitted by me are true and correct. I have not kept any information secret. Should it, however, be found that any information furnished herein is fraudulent/ incorrect or untrue in material particulars, I realize that I am liable to criminal prosecution. I agree to abide by the Rules and Regulations governing this examination and as contained in the instruction booklet. I understand that my admission will be provisional and if at any later stage, I am found ineligible, it will automatically stand cancelled. Date: Place:

………………..

Signature of the Candidate

Web Copy

Last Date 10–1–2007

Roll No………………… (Leave Blank)

RAJASTHAN UNIVERSITY OF HEALTH SCIENCES, JAIPUR
Application Form for Pre-P.G. MDS Examination- 2007 For admission to MDS Courses (To be kept in the record of the Dental College) AFFIX YOUR RECENT PHOTOGRAPH Duly signed by the candidate and attested by Principal of his/her Dental college/or DMHS, Jaipur

Enter the Category Code for which application form is being submitted: In-Service- SC 1 NS General- SC 5 Category Code In-Service- ST 2 NS General- ST 6 In-Service- OBC 3 NS General- OBC 7 In-Service- Others 4 NS General- Others 8

1. Full Name 2. (a) Father’s Name (b) Mother’s Name 3. Date of Birth 4. Full Postal Address

………………………………………………………………………….. ………………………………………………………………………….. ………………………………………………………………………….. ………………………………………………………………………….. ………………………………………………………………………….. ………………………………………………………………………….. City ……………………...………………PIN…………………………

Telephone Nos.(with STD codes)

(R) ……………………………. (O) ………………………… (M)……………………………. (Fax)……………………….

5. State/Union Territory to which you belong …………………………………………………………. 6. Nationality ……………………… 7. Sex …………………………………. ………………….

8. Which Category you belong to? SC/ST/OBC/General (SC/ST/OBC candidates must attach an attested copy of the caste certificate)

9. Are you entitled to reservation under In-Service Category ? Yes/No. ………………. (If yes, attach the requisite certificate issued by DMHS,Jaipur) In case of army personnel, certificate to be issued by Chief of Army Dental Services. 10. Eligibility Category (A/B/C) of Non-Service Candidates ………………………….. [See Instruction Booklet for details about A/B/C and attach attested copy of requisite certificates]

Category A must specify following details of Final BDS Examination of University of Rajasthan Roll Number ………………………. Year of Examination ………………. Category B, must specify details of All India Competitive Examination Name of Examination Conducted by Government Agency Name of College Whether College is recognized by DCI?
Attach the certificate from the Principal of Dental College and attested copy of Bonafide Resident Certificate

Category C, must specify following details Name of Husband Address Date of Marriage
Attach attested copy of the Marriage Certificate and attested copy of Bonafide Resident Certificate of husband

11. Date of Completion of Internship Training ………………………………………………………….. 12. Permanent Medical Registration Number with the State Dental Council ………….........………….. 13. Academic Qualifications: Details of Marks obtained in BDS Examination. BDS
Name of the University/ Institutions State in Which College/Institution situated Month & Year of Passing Percentage of Marks Obtained Total No. of times appeared in the examination including the one in which passed

Ist BDS 2nd BDS 3rd BDS Final BDS Attach attested copies of the Degree/Provisional Certificate and Mark-sheets related to the BDS Examinations mentioned above. 14. Have you already done Post-graduate Course in any other Subject? Yes/No.……………………… (If yes, mention the subject, year and College) ………………………………………………………. 15. Are you doing P.G./Diploma Course in any Subject? Yes/No. ……………….. (If yes, mention the subject, year and College) ……………………………………………………… Date: Place: Signature of the Candidate ……………

For Office Use

RAJASTHAN UNIVERSITY OF HEALTH SCIENCES, JAIPUR
Pre-PG Dental Examination -2007
(For admission to MDS Courses)

ADMISSION CARD
Roll No………………… (Leave Blank)

AFFIX YOUR RECENT PHOTOGRAPH

Duly signed by the candidate and attested [Candidate must fill in his/her name and father’s name in his/her own writing.] by the Principal of Please admit Dr. …………………………………………………………………. his/her Dental College/or DMHS, Son/Daughter of Mr./Ms./Dr. ……………………………………………….…… Jaipur

to the Pre-P.G. Dental Examination 2007 which will be held on 28-01-2007 in two shifts (Paper I - 09:00 - 11:00 Hrs. and Paper II -12:30 -14:30 Hrs) at the following examination centre:

(------------------------) Convener Pre-PG Medical Examination 2007

INSTRUCTIONS
1. The Pre-P.G. Dental Examination shall be conducted at Jaipur only. All candidates are required to appear at the Pre-P.G. Dental Examination at their own expenses. 2. The candidates are expected to take their seats 15 minutes before commencement of the examination. No candidate coming after 15 minutes of the commencement of the examination shall be permitted to appear in the examination. 3. Candidate will be required to produce Admission Card before he/she is allowed to enter the examination centre. 4. Candidate must bring two blue/black ballpoint pens. 5. Candidates should read the instructions given on OMR Sheet carefully. All entries must be filled by ball point pen. Darken the appropriate circles/ovals using blue/black ballpoint pen only. Therefore, the candidates are advised to finalize their choice before marking on OMR sheet. Overwriting is not allowed. If you darken more than one circle, your answer will be treated as wrong. Do not make any stray marks on the answer sheet. Do not fold the Answer sheet. Rough work must not be done on the answer sheet. 6. No candidate shall be allowed to carry any text material written or printed, bits of paper or any other material except the admission card inside the hall. Cellular/Mobile phone/Pager/Calculator etc. will not be permitted in the examination hall. 7. The candidate shall maintain silence and attend to their paper only. Any disturbance by the candidate at the examination will be deemed misbehaviour and the candidate involved in such activity shall forfeit his/her right to continue in the examination. The decision of the Centre Superintendent shall be final and conclusive in the matter. 8. No candidate shall be allowed to go outside the examination hall till the completion of the examination. 9. Candidates will be allowed to take with them the carbon copy of the OMR Sheet. Writing anything on the Admission card/ Carbon copy of OMR sheet or any stray paper will be treated as unfair means. Candidate should not temper with the question booklet or tear any page out of it. 10. The Jurisdiction of the court cases will be at Jaipur only.

FOR IN-SERVICE CANDIDATES ONLY
Name………………………………………………………………..……… 1. Designation and Present Place of Posting…………………………..……… 2. R.P.S.C. Selection Order No. & Date……………………………………… 3. Date of Joining and Place……………………………………………..……

AFFIX YOUR RECENT PHOTOGRAPH Duly signed by the candidate and attested by Director, Medical & Health Services, Jaipur

DECLARATION
I have served the Government of Rajasthan continuously since _______________ and have completed more than three years after regular appointment by RPSC. As such I am eligible for admission to MDS Courses in ‘In-Service’ category. Dated…………………. Signature of the Candidate

No.

CERTIFICATE

Date:

This is to certify that Dr. ……………………………………………………………..……………..…. Son/Daughter of ………………………………………………………..is posted at………………..… She/He was appointed vide State Government Order No. ……………………….Dated…………….. . and served the State Government from……………………….…….to………………..……………..… His/her date of birth as entered in the service record is……………………………………and he/she is below 45 years of age. It is certified that he/she is eligible for admission to postgraduate courses through the Pre-PG Dental Examination 2007 under the In-Service category as per University Ordinances 278 E & G as modified and adopted by Rajasthan University of Health Sciences, Jaipur, Government of Rajasthan rules and directives in force. Date: Director Jaipur Medical & Health Services Government of Rajasthan, Jaipur (Seal)

Note: The signing authority is requested not to alter any part of the certificate. Application of ‘In-Service Candidates’ shall not be accepted by the University, if not sent through proper channel with above certificate.

CERTIFICATE FOR ARMED PERSONNEL
This is to certify that Dr. ……………………………....... Son/Daughter of ................................................... was appointed vide Govt. Order No. ............................. dated ........................ to Armed Dental Corps. and have served army. His/Her date of birth as entered in service record is .......................... and he/she is below 45 years of age & was born in state of Rajasthan/bonafide resident of Rajasthan. Signature with Seal of Authority

FOR NON-SERVICE CANDIDATES ONLY
1. Full Name ………………………………………………………. 2. Father’s Name …………………………………………………... 3. Date of Birth …………………………………………………….. 4. Address …………………………………………………………. ………………………………………………………….. ……………………………………………………………. 5. Years of BDS study from …………………..to…………………………………… 6. Name of College ……………………………………………………………………. 7. State ………………………………………………………………………………. Signature of the Candidate AFFIX YOUR RECENT PHOTOGRAPH Duly signed by the candidate and attested by the Principal of Dental College last attended

Certificate to be given by the Principal of the Dental College (only for Category ‘B’ candidates).
This is to certify that Dr. ……………………………………………………………………..…….. Son/Daughter of ……………………..………………………………… has studied in this institution w.e.f………………to……………………….and passed Final BDS Examination held in

……………………………….(Month)………………..(Year) under Roll No .………………………… He/She was admitted to the BDS course on the basis of his/her standing at Merit No....................... in the examination (Name of Examination) ........................................................................................................ conducted by (Name of Government Agency) ......................................................................................... This college is recognized by the Dental Council of India.

Date: Place:

Principal Dental College (Seal)