fnaMksjh jksM]EgljQG]ukf'kd&422004 Dindori Road, Mhasrul, Nashik-422004

Tel : (0253) 2539228/230(UG), 2539232(PG) Fax : (0253) 2539231/33

Website : www.muhs.ac.in, E-mail : eligibility@muhs.ac.in

MkW- dkfynkl n- pOgk.k Dr. Kalidas D. Chavan

,e-ch-ch-,l-] ,e-Mh-(U;k;oS|d'kkL_k) M.B.B.S., M.D. (Forensic Medicine)
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G:\Ph.D. Circular 2019-20.doc

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Name of Account : Registrar Maharashtra University of Health Sciences, Nashik
Saving Account No: 00641450000649
Name of Bank : HDFC Bank, Thatte Nagar, Gangapur Road Branch, Nashik
IFSC Code : HDFC 0000064
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G:\Ph.D. Circular 2019-20.doc

 A Annexure - I

egkjk"V! vkjksX; foKku fo|kihB] ukf'kd

MAHARASHTRA UNIVERSITY OF HEALTH SCIENCES, NASHIK
fnaMksjh jksM] EgljQG] ukf'kd&422004 Dindori Road, Mhasrul, Nashik-422004

APPLICATION TO GRANT ELIGIBILITY FOR

DOCTOR OF PHILOSOPHY COURSE
(Incomplete Applications will be rejected) Passport size
Photograph
attested by the
Speciality: Dean/Principal
with Stamp
Academic Year : 2019-20

1) Full Name of the applicant

(As per Qualifying Degree)
Name in Marathi (Devnagari)
2) Gender (Male/Female)
3) Date of Birth and Age (dd/mm/yyyy) DOB: Age :
4) Date of joining this course
5) Name of the Institution/College
6) Address for Correspondence

PIN:
Permanent Residential Address

PIN:
Email id
Mobile No 1) 2)
Residential Landline No with STD Code
7) Nationality
8) Educational Qualification :
Name of Course Name of the University Month & Year
Diploma/Degree of passing
Diploma
Bachelor’s Degree

Post Graduate Degree

Additional
Qualification (if any)

G:\Ph.D. Circular 2019-20.doc

 9) Central / State Council Permanent Registration
number & its date
10) Category under which admitted
SC/ST/VJ/NT1/NT2/NT3/OBC/SBC/Open
11) Category of Student
SC/ST/VJ/NT1/NT2/NT3/OBC/SBC/Open
12) Whether willing for organ donation after
accidental death for transplantation (Yes/No)

13) Check list of documents to be submitted in original along with an attested photocopy:

Sr. Attested
Original
No. Name of Documents to be attached Photocopy
Yes/No
Yes/No
1 Nationality/Domicile Certificate issued by District Magistrate/Additional District
Magistrate / Chief Metropolitan Magistrate/ Pass Port (Adhar Card/ Pan card
Not allowed)
2 Joining letter issued by Centre
3 Diploma Degree Certificate UG & PG Both
4 Certificate of P.G. Degree in the concerned /prescribed allied subject OR
Certificate of P.G. Diploma (registered in the concerned schedule of respective
Central Council) OR
Certificate of D.N.B. (with two research papers published in National or
international Journals)
5 Central/State Council Registration Certificate (UG & PG) with Additional
Qualifications Registrations
6 Caste Certificate (If applicable)
7 Caste Validity Certificate
8 Valid Non-Creamy Layer Certificate for (VJ,NT,OBC,SBC etc.) (If applicable)
9 In case change in name Gazette copy/Marriage Certificate in
10 NOC From Servicing Institute (Part Time/ Full Time)
11 Education Gap Certificate (Format attached) (If applicable)

Note: 1) It is mandatory to the candidate belonging to reserved category to submit Caste Certificate duly
supported by Caste Validity Certificate & valid Non-creamy Layer Certificate (where ever
applicable), failing which proposal will not be accepted.

2) Kindly submit the above said documents in above sequence with one set of Original and one set of
attested photocopies.

G:\Ph.D. Circular 2019-20.doc

 DECLARATION BY THE CANDIDATE

I hereby declare that the above information furnished by me is correct. If any information furnished by me is
found fraudulent /incorrect/ untrue at a later date, I am aware that my admission is liable to be cancelled and
Civil/Criminal action can be prosecuted against me. I am fully aware that the University shall return my application of
enrolment towards non-compliance of documents within a period of 30 days from the date of admission. I have
perused eligibility rules for admission and thereby declare that I am eligible to be enrolled with the University.

I am also aware that late fees shall be attracted towards late submission of eligibility documents as
prescribed by the University

Date: ………………….. Signature of candidate

CERTIFICATE BY THE HEAD OF THE INSTITUTION/COLLEGE

We certify that entries made by the candidate in the application form are correct and have been verified from
the original documents. On perusal of documents, it is found that the candidate is eligible for the admission of the
course as per prescribed norms. It is apprised to the candidate to comply-with requisite documents within a period of
30 days, failing which his/her admission shall be cancelled by the College.

Place :

Date :

Signature of the Head of the Institution/College

Seal

G:\Ph.D. Circular 2019-20.doc

 Annexure –A
Self – Declaration

Applicant’s
Photo

I ………………………………………………………………………………………………………Son Daughter

of ……………………………………..……………………. aged ………………..………………..……………,

occupation ………………………………………………with UID No. ………………………………………….

Hereby declare there is a gap from ………………………………….to ………………………………….after

my last academic qualification and I have not taken admission to any course during the said gad period.

The information provide above is true and correct to the best of my personal knowledge,

information and belief. I fully understand the consequences of giving false information. If the information

is found to be false, I shall be liable for prosecution and punishment under Indian Penal Code and / or

any other law applicable there to.

Place: ………………………………. Applicant’s Signature: ……………………………….

Date: ……………………………….. Applicant’s Name: ……………………………………

G:\Ph.D. Circular 2019-20.doc