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Roll No. .................................

ADMISSIO N FORM-2011
FOR MBBS/BDS IN MEDICAL/DENTAL

(Leave Blank)

COLLEGES OF RAJASTHAN
Middle Name Last Name

(No colum n shoul d be lef t blank . If no t applicable , it shoul d be m arke d NA. Use CAPITAL LETTER S only)

First Name 1. Nam e of the candidat e (IN BLOCK LETTERS) 2. Father s Name 3. Mother s Name 4. *Guardian s Name 5. Relationship
*Any person, other than the parents of the candidate, only if the parents are not alive or are insane. can becom e guardian

Affix your recen t Coloured photograph duly signed by the candidate and attested by a Competent officer as explained in Information Booklet

6. Date of Birt h

7. Age on 31 st December,

2011

8. Sex

(DD)

(MM)

(YYYY)

(Years)

(Months )

(Days)

Male/Female

9. Nationalit y ........................

. 10. Religion.............................. . 13. Rural/Urba

. 11. State............................ n .............................................

12. Place of Birth........................................

14. Occupatio n of Father/Guardian.............................. (Govt./Pvt.)

. Annua l Incom e Rs. ..........................

If in Govt. Servic e mentio n detail s of the post.................................................................... 15. (i) Addres s for Correspondenc e (ii) Candidate s Permanen t Address

PIN Telephon e No. with STD Code Telephon e No. with STD Code

PIN

Mobile No.

Mobile No.

16. Categor y (Genera l Boy/S C Boy/ ST Boy/ Scheduled Area Tribal Boy/OBC Boy/ SBC Boy /Genera l Girl/S C Girl/S T Girl/Scheduled Area Triba l Girl/OB C Girl/ /SBC Girl) 17. Additiona l Category , if any (PH/DP/PM) (1)

18.

Detail s of Educationa l Institution s wher e the candidat e studie d durin g las t 10 years.
Years Name of Institution Class in which Studie d Nam of City/Village e and S tate

2010 -201 1 2009-2010 2008-2009 2007-2008 2006-2007 2005-2006 2004-2005 2003-2004 2002-2003 2001-2002

DECLARATIO N BY THE CANDIDATE


1. I have rea d the rule s an d regulation s of RPMT-2011 . Regardin g admissio n to the Medical/Dental Colleges , I find mysel f eligibl e for the same . I realis e tha t if th e Admissio n Boar d decides that I am not eligible, I shall abide by its decisions. 1 do solemnl y affirm tha t the statemen t an d informatio n furnishe d by me as abov e and also in the enclosure s submitte d are true . I realis e that , if any informatio n furnishe d therei n is foun d untru e in material particulars, I shall be liable to criminal prosecution as well as forego my admission and to be removed from the College, if already admitted. I shall abide by the decision of the Admission Board. I also undertake to pay the College, Hostel and other dues regularly. I hereby agree, if admitted, to abide by the rules and regulations at present in force and those that may here after be made for the administration of the college and I undertake that so long as I am a student of the College , I will do nothin g eithe r insid e or outsid e the Colleg e tha t will interfer e wit h its orderly workin g an d discipline. I also declare that : (a) I have not been convicted of any criminal offence nor have I been released on bail in connection with a crimina l case. (b) No case of criminal offence or moral turpitude is pending against me in any Court of Law. (c) No complaint or F.I.R. has been lodged against me by the University/Principal of a Constituent College/School. (d) I have not resorted to any act of indiscipline in past year(s). (e) I have not bee n debarre d from appearin g in RPMT earlier. I understand that if all the necessary documents are not appended with the form, the form is liable to be rejected. Affix Left Thum b Im pression Affix R ight Thum b Im pression Signature of the C andidate

2.

3. 4.

5.

6. 7.

Verified by : Date : ..................2011

(Signature & Seal) Signature & Thumb Impression should be verified and marked in presence of Principal of School/College last attended/ Gazetted Officer/Executive Magistrate. Note : Candidate must sign the form and affix left & right Thumb Impressions failing with the application form will be rejected.
Place : ..........................

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CERTIFICATE PARENTS/GUARDIAN
1. th e natura l father/mother

NO. 1 S CERTIFICATE
. solemnl y affirm tha t I am d my monthly

I, ......................................................................................... incom e is Rs . .............................. OR #I................................. son/daughte

* of Shri/Kum . ...........................................an

. solemnl y affirm tha t Shri/Km . ..................................

. is the

r of Shri.......................................................... . (stat e relationship)

. and , I am the guardia n of

Shri/Kum ari............................................ He/She is my................................... 2.

. as his/he r parent s have died/becom e insane. in my sons/ o ar e true . I e in material removed from and

I hereb y solemnl y affirm tha t the statemen t an d informatio n furnishe d daughters/ward s applicatio n as also in the enclose d enclosure s theret realiz e tha t if any informatio n furnishe d therei n is foun d to be untru particulars, my ward is liable to criminal prosecution and if admitted, to be the institution.

3.

I undertake to be responsible for his/her conduct and for maintenance of discipline shal l pa y regularl y all his/he r expense s durin g his/he r stay at the institution. Signatur e of Father/M other/G uardian

Date : .................2011 Place : .........................

*If natura l fathe r is not alive. #If natura l parent s are not alive or are declare d insane.

CERTIFICATE CERTIFICATE
of my School/College

NO. 2 LAST ATTENDED


Sh. ................................ or

OF PRINCIPAL OF THE SCHOOL/COLLEGE


Son/Daughter of has passed

I certify that Shri/Kumari.......................................

Exam in all the subject s of Senio r Secondary , (10+2) Record Table as below :
Biology
Marks Max. Mark Obtained

Equivalen t examinatio n with particular s given in Academic Academic Record Table


Roll No. Year of Passing Board Division Physics
Marks Max. Mark Obtained

Chem istry
Marks Max. Mark Obtained

English
Marks Max. Mark O Obtaine d

Date : ..................2011 Place : .........................

Signatur e of the Hea d M aster/ with Office Seal (3)

Principa l

CERTIFICATE

NO. 3

CERTIFICAT E OF ELIGIBILITY
NOTE : Any one out of following eleven the form shall be rejected. Certificates (I-XI) is necessary, failing w hich

ELIGIBILITY CERTIFICATE
i ..................................

UNDER RULES 3 (C) (i)


. Son/Daughte examination r of..................................... (X-XI & XII) continuously as

I Certif y tha t Shri/Kumar has studied

for the last three years of the qualifying

a regula r candidat e in recognise d Institutio n in Rajastha n and is an India n National.

Date............... . 2011 Plac e ............. .

Signatur e of the Hea d M aster/Principal/ Hea d of Institutio n las t attended With Official Seal

II
I certif y tha t Shri/Kumar Father/M other he/she Proforma

CERTIFICATE

UNDER RULES 3(C) (ii)


. is the natura l Son/ . an d his/her that in institutions

i ................................................................. residing in Rajasthan

Daughte r (no t adopted ) of Shri/Shrimati........................................................ has been continuously has studied on Page 2. for at least 5 years in this period in recognised educational

for a period of 10 years and

Rajasthan . The detail s of perio d of stud y in recognize d educationa l institution s are given in

Dat e ..............2011 Plac e ................... .

Signatur e of the Distric t M agistrate/ Addl. Distric t M agistrate/ Sub . Divisiona l Magistrate Executiv e Magistrate

III CERTIFICATE UNDER RULES 3 (C) (iii) BONAFIDE RESIDENT CERTIFICATE

The candidate should subm it by th C petent e om A uthority Nam e of Competen t Authority Officia l Address Dat e of Issu e of certificate Stat e wher e studying

attested copy of h er Bonafide is/h of G overnm ent of R ajasthan. ........................................ ........................................ ........................................ ........................................

Resident

Certificate

issued

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IV

CERTIFICATE

UNDER RULES 3(C) (iv) a

I certif y tha t Shri/Sm t .......................................................................... . Father/M othe r of Shri/Kumari............................i s serving/retire d (i) employe e of Governmen t of Rajastha n or (ii) is an Officer of All India Service born on the State Cadre of Rajasthan. He has served for mor e tha n 3 year s with th e Stat e Governmen t as........................... . for th e perio d from.....................to.......................... . in the Departmen t of............................ . (designation). Date............... . 2011 Place ............. . Signatur e of the Employer/ Hea d of the Department Designatio n and Seal

CERTIFICATE

UNDER RULES 3(C) (iv) b

Certif y tha t Shri/Shrim at i ....................................................................... . Father/M othe r of Shri/Kumar i .......................................................... . is a serving/retired , permanen t employee of Governmen t Undertaking/corporation/Improvemen t Trust/Municipa l Board/Council/ Panchaya t Samiti/Co-operativ e Bodies , dut y constitute d by the Governmen t of Rajastha n by an Act of Law who has put in atleast three years of service on the last date of submission of application in the year of admission. He/she is in service as...................... in the....................... sinc e .................. . (designation)........................................ . (Body/Dept.) Date............... . 2011 Place ............. . Signatur e of the Employer/ Hea d of the Department Designatio n and Seal

VI

CERTIFICATE

UNDER RULES 3(C) (iv) c

Certif y tha t Shri/Shrim ati........................................................................ . Father/M othe r of Shri/Kumari.................................... . is a serving/retired , permanen t employe e of University (Name ) ........................................................ . in Rajastha n or Boar d of Secondar y Education, Rajastha n an d ha s pu t in atleas t thre e year s servic e on the las t dat e for submissio n of applicatio n in the year of examination . H e/sh e is in servic e as.................................i n the ......................................... . sinc e .................... . (designation ) ........................ . (Body/Dept.) Date............... . 2011 Place ............. . Signatur e of the Employer/ Hea d of the Department Designatio n and Seal

VII

CERTIFICATE UNDER RULES 3 (C) (v) FOR DEFENCE PERSONNEL OF RAJASTHAN ORIGIN

I certif y tha t Shri/Kumari........................................................i s a natura l Son/Daughte r of Shri/Shrim ati............................................. . an d his/he r Father/M othe r is serving/retired permanen t employe e in India n Defenc e Servic e an d he/sh e is of Rajastha n origi n an d the home town as given by him /her at the tim of his/her entry into service is................................. e town............................ D ist.......................... State.................................... H e/she com es under priority * ................. . m ean t for th e Ward s of Defenc e Personnel. (*See Prioritie s I to IV as mentione d in Informatio n Booklet). Date............... . 2011 Plac e ............. . (5) Signatur e of the Employer (with Official Seal)

VIII

CERTIFICATE REGARDING DEFENCE PERSONNEL NOT OF RAJASTHAN ORIGIN BUT SERVING IN RAJASTHAN

I certif y tha t Shri/Kum ari...................................................... . is a natura l Son/Daughte r of Shri/Shrim at i .............................an d his/he r Father/M othe r is servin g employe e of Defence Service of India. He has been in the service for the last..................... years and is working on the post of .......................................... from .................. in this unit and is posted in Rajasthan since......................and is continuin g in Rajastha n at present . He/Sh e come s unde r Priority ...................................... . m ean t for Defenc e Personnel. Date............... . 2011 Plac e ............. . Signatur e of the Employer (with Official Seal)

IX

CERTIFICATE UNDER RULE 3 (C) (vi) FOR PARA MILITARY PERSONNEL OF RAJASTHAN ORIGIN
i ................................................. . is a natura l Son/Daughte r of i ............................................ . an d his/he r Father/M othe r is serving/retired town

I certif y tha t Shri/Kumar Shri/Shrim at

perm anen t employe e in Par a Militar y Forc e and he/sh e is of Rajastha n origi n and the home town as given by him /her ..................................... Date............... . 2011 Plac e ............. . at the tim of his/her e . Dist............................... entry into service is ............................. . state............................ Signatur e of the Employer (with Official Seal)

CERTIFICATE REGARDING PARA MILITARY PERSONNEL NOT OF RAJASTHAN ORIGIN BUT SERVING IN RAJASTHAN
. is a natura l Son/Daughte . an d his/he r Father/M othe r of r is

I certif y tha t Shri/Kumari...................................................... Shri/Shrim ati......................................................................

serving employee of Para Military Forces. He has been in the service for the last......................... year s an d is workin g on the pos t of ..................................since..............................i unit and is posted in Rajasthan Date............... . 2011 Plac e ............. . from ....................... and is continuing in Rajasthan n this at present.

Signatur e of the Employer (with Official Seal)

XI

CERTIFICATE UNDER RULE 3 (C) (vii) FOR SON/DAUGHTER OF A JUDGE OF RAJASTHAN HIGH COURT
. is a natura l Son/Daughte stating that such benefit r of is not i .............................................................................. to that he/she subm its an undertaking/affidavit in any other State. Signatur e of the Employer Rajastha n High Court (with Official Seal) (6) or availed by him /her . A Judg e of Rajastha n High

I certif y tha t Shri/Kumari....................................................... Shri/Shrim at Court subject being claimed

Date............... . 2011 Plac e ............. .

FOR OFFIC E USE ONLY

Total Marks Obtained

in RPMT-2011

Nam e of the Colleg e allotte d ............................................................................. (1st Counselling)

Signatur e of Chairman/Convene r RPMT-2011 Counsellin g UG Admissio n Board.

Chang e (if opted)/fres

h allotmen t ..................................................................... (2nd Counselling)

Signatur e of Chairman/Convene r RPMT-2011 Counsellin g UG Admissio n Board.

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DESCRIPTIO N OF ESSENTIA L DOCUMENTS


(TO BE FILLED BY THE CANDIDATE)
1. List of documents : [M ark tick (3) if photostat/true Booklet) is enclosed and Cross (X) if not enclosed.
S.No. D ocum ent

copy (duly attested

as per Information
Enclosed (3) Not enclose d (X)

1. 2. 3. 4. 5.

Marksheet

of passing the Secondary

School Exam.

Marksheet of passing the Senior Secondary School/10+2 or equivalent Exam. (if appeared-write appeared) Secondary School Exam. Certificate in support of Date of Birth (if it is not mentioned in the mark sheet of Secondary School exam.) Certificate in proof of desired reservation category (For SC/ST/ Schedul e Triba l Area/OB C only) issue d by the competen t authority. Certificat e of Physicall y Handicappe d (for PH only) clearl y mentioning the locomoto r disabilit y of lower limb s betwee n 50% to 70% issue d by the competen t Medica l Boar d as require d in Informatio n Booklet.

2. 3.

Certificate of eligibility under clause 3(C) printed in the Form A under the heading of Certificate No. 3 (Any one Certificate out of eleven must be filled in and signed by competent authority) The candidate applying under Defence Personnel of Rajasthan Origin m ust ensure that his/her priority (I to IV as mentioned in Information Booklet) is clearly mentioned in the Certificate Printed in the Form A. Th e candidat e is als o require d to enclos e photocop y of relevan t certificate , if applying under Priority II or III. Two coloure d photograph s with nam e of candidat e and his/he r form num r on the bac k of the be photographs. Board at the tim of e

4.

Note : 1. Do not enclose any original certificate w ith A pplication Form . 2. All original certificates have to be produced before U. G. A ission dm Interview (Counseling)

FOR OFFICE USE ONLY


10th M arksheet 12th M arksheet Date of Birth C ertificate R eservation category C ertificate PH C ertificate Eligibility C ertificate DP Priority

Eligibilit y requirement

s fulfille d

YES/NO

Remark s (If any) .................................................................................................................

Signature of Form Scrutinser Office of Convener RPMT-2011 Rajasthan University of Health Sciences , Jaipur

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ADMISSION FORM RPMT-2011

1. 2. 3. 4.

Roll No Category. Over all Merit No.. Name of Candidate

Affix your recent Coloured Photograph duly signed by the candidate and attested by a competent officer as explained in Information booklet

5.

Fathers Name

6.

10th Marks % (Total % All the Subjects).

7.

10+2 Marks % (% of only Phy., Chem. & Bio.)..

8.

R.P.M.T. Marks .

Signature of Candidate

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