VIJAYANAGAR INSTITUTE OF MEDICAL SCIENCES, BALLARI, KARNATAKA-583104 ATTENTION SUPER SPECIALITY DEGREE (Mch) CANDIDATES 2023-24 \ \ 0 Pri |19 I am here by declare that the I am fully read the terms and conditions of NEET 2019 and I am aware the facts and I am willing to participate in Second round in AIQ NEET 2021 Willing / Not Willing (indicate Y which your willing and wish) Note : Iam aware of all the fact and read carefully before signed below: Date : Place : Signed by me Name of the CandidateREGISTER PROFORMA TOBE FILLED BY THE CANDIDATES (ADMITTED) TO MEDICAL COLLEGE VIMS BELLARY. OT | Register Number 2 | Date of Admission 03 | Name in Full (Capital Leters) 04 _ | Father's Name, Occupation & Address O Guardian when a father is not alive) 05. | Mobile No, & Email 1D 06 | Blood Group 07 _ | Income of parent or Guardian per annum 08 | Place of Binh 09-_| Date of Birth 10 | Race of Caste & Religion TT___| Native District 12 _ | Karnataka or Non-Kamataka 13 | Former School or College lengih of attendance in i 14 | Highest Examination passed 15 | Class on entering 16 | RegNo// Final MBBS’ Marks Max/Sec, & Passing Date: 17 | Whether vaccinated or had small pox 18 _ | Amount of admission and other fees paid on admission 19 | Receipt No. and Date 20 | Class on leaving 21 | NoDate of leaving certificate 22 | Remarks NOTE: The candidates are required to fillonly 3 to 20 columns. Place: Date : Signature of the candidateVIJAYANAGAR INSTITUTE OF MEDICAL SCIENCES, BALLARI ADMISSION PROFORMA TO BE FILLED BY THE CANDIDATES (ADMITTED) TO THE POST GRADUATE DEGREE / DIPLOMA. MEDICAL COLLEGE VIMS BELLARY.(RGUHS) FORM, - II OL Course for Admission (CAPITAL) Degree / Diploma 02 ‘Name of the Candidate NAME IN FULL (CAPITAL) 03 Father’s Name Name In Full (CAPITAL) 04 Mother's Name (CAPITAL) 05 Sex 06 Student Adress NAME IN FULL ( CAPITAL) Cell No. Email ID Religion Mother Tongue Caste Sub Caste ‘Nationality Rural Urban, NEET Rank NEET % Qualifying Exam Register No.(MBBS) Passed Year Date (MBBS) University MBBS) MBBS Final Year Max Marks MBBS Final Year Sec Marks Date of Admission Date of Birth Blood Group Signature of the candidateVIJAYANAGAR INSTITUTE OF MEDICAL SCIENCES, BALLARI ADMISSION PROFORMA TO BE FILLED BY THE CANDIDATES ADMITTED) TO THE POST GRADUATE DEGREE / DIPLOMA MEDICAL COLLEGE VIMS BELLARY.(MCI FORM, - I 01 | Course for Admission (CAPITAL) Degree / Diploma 02 | Name of the Candidate NAME IN FULL ( CAPITAL) 03 | Date of Birth 04 | Admitted Seat (Recognized / Permitted) 0. a Admitted by (AIQ / State) 06 | Category 07 | PH (Yes/No) 08 | NEET Roll No. 09 | NEET AIQ Rank 10 | NEET State Rank 11 | NEET Percentile of Marks 12 | Stipend paid (Yes / No) 13 | Stipend Paid Amount 14 | Stipend Paid Govt Institute 15 | Medical Council Registration (Mention the State Council No.) 16 | Medical Council Registration (Mention the State Council) | Ex: Karnataka /TN Ete., 1 a Date of Admission Signature of the candidate1. Annexure 4 Compulsory Rural Service Bond Format for non in-service Candidates (To be submitted at college at the time of admission’ (To be executed on a stamp paper of Rs. 200/- duly notarized) IDr. aged ___Years S/o, Permanent of Resident of . at present residing at 4 do hereby swear on oath as follows; That I am admitted to VIJAYANAGAR INSTITUTE OF MEDICAL SCIENCES, BALLARI College for PG/Broad-specialty/Degree/Super Specialty course in (mention the subject) under ALL INDIA / State quota. 2. a 4. I am submitting the bond after reading and fully understanding the Karnataka Compulsory service by candidates completed Medical course act 2012 and its amendment time to time. I state that I have admitted under non-in-service State quota / All India quota. I understand that all the candidates (other than the candidates who have undergone compulsory rural service after award of MBBS degree) who take admission to PG Medical Degree/Diploma courses and successfully complete the Post Graduate Degree/ Diploma shall under go one-year compulsory service in Government hospital in urban area as per Karnataka Compulsory service training by the candidates completed medical courses (counseling, allotment, and certification) as per Karnataka Compulsory Service Act 2012 as amended in time to time and rules there under to the said act. . I am fully aware of the fact that the candidates will be entitled to only temporary registration till completion of such service. I shall be abide voluntarily to the said condition. BOUNDENAnnexure 4-A UNDERTAKING AS REQUIRED UNDER RULE 15(5)OF THE KARNATAKA CONDUCT OF ENTRANCE TEST FOR SELECTION AND ADMISSION TO THE POST-GRADUATE MEDICAL AND DENTAL DEGREE AND DIPLOMA COURSES RULES, 2006 FOR CLINICAL SUBJECTS IN MEDICAL / DENTAL COURSES. ‘o be executed on a stamp paper of Rs. 200/- duly nota: 1 Dr, Slo, aged __ years, having Aadhar no PAN No. permanent resident of and presently residing at (herein after referred to as BOUNDEN) do hereby swear on oath as follows:- 1) That I am admitted to ‘Government’/‘Government-quota’ seat for ‘All India quota’/State quota’ in YANAGAR INSTITUTE OG MEDICAL SCIENCES, BALLARI college for post-graduate medical/dental degree/diploma_ in (Indicate the subject)during the centralized counseling for admission to post-graduate courses-2021. 2) Lam aware of the fact that the Fees for ‘Government’/“Government-quota’ seat is highly subsidized, I shall be under an obligation to serve the State of Karnataka for a minimum period of three years after completion of my post- graduate course as required under rule 15(5) of the Karnataka Conduct Of Entrance Test For Selection And Admission To The Post-Graduate Medical And Dental Degree And Diploma Course Rules, 2006. After reading and fully understanding the above mentioned Rules, I have opted for the ‘Government’ /“Government-quota’ seat. 3) In compliance with the above Rule 15(5), I hereby furnish the undertaking voluntarily, with my free will that I shall abide by the condition to serve the Government of Karnataka for a period of three years after completion of my post-graduate course in any location decided by the Government of Karnataka, and that If I fail to comply with undertaking, myself and/or my sureties mentioned below do hereby bind ourselves and each of us, our and eachof heirs, executors and administrators jointly and severally to pay to the Governor of Karnataka on demand, we shall pay a penalty of Rs. 50.00 lakh (RUPEES FIFTY LAKH ONLY) for post-graduate degree/ Rs. 25.00 lakh (RUPEES TWENTY FIVE LAKH ONLY) for post-graduate diploma to the Government and only after payment of penalty, I shall collect my original documents which are in the custody of the Institution. 4) I am enclosing the details of two sureties along with their self- attested copies of PAN card and Aadhar card. Signed this day of by the Bounden DETAILS OF SURETIES 1. Name : S/o, D/O, W/o «esse» Yeats, having Aadhar no.. permanent resident of .... and presently residing at .. R ‘Name: S/o, D/O, W/o..» PAN No. .. ... years, having Aadhar no... permanent resident of presently residing at .... BOUNDEN SURETIES WITNESS 2. (Note: Candidates have to submit the AADHAR copy / PAN copy of the witness / Sureties compulsorily) (Candidates have to signed in each page of the bond)BAseob d800 acirewmoad Directorate of Medical Education odorant Hy, dortvoch-9 Ananda Rao Circle, Bangalore-9 ‘email: dmekarnatake@vahoo.com Roady Spp/antart/38/2017-18 Bazo8: 19-04-2018 ©O82 mpi og 2OIS-I9Se MOS Asta RAYS eles wodscds eelOrrieod BRO mempers aed ates wf eatwog—4 vo adey aac Bair Aes Gide eaduog—4 a gd moatrivay ado eco Botronh eatdeest seas a7, COYCD:- Ross, WHE (HP) / 91/ wate / 2018 O5r08.06-04-2018, KOS Aelody Aowonacios vi shovs seobuodwasdedond 2018-I9de mong Asta mBEQyy eitelen meus wom mpROS aBcon Uo BOGS Aero Eacncaadys weorrisy Amro Aelgeob mdenarioh sey axa carla Dts, Hise Meare zee atlohs eames aecwoonod cyaesuet Srouend shee moubridad, xYxsod dimmride xaessewnc, BeQow evgeadd ado Amro aIjsrod eaeearie Aciereecy marke Beatdsed Sie AREA ayaisecd mdcariy annie aeaky aigjseod mescory epowmecbrive Ask, De mdearvg Xero kactmnBchy gad keewerien zee added amprritos Bras dahesog Aerwadsocd desu ames emocirvey, sich Scie, EUS Toe mBpMdS Heer exdnrat amedsios ot choot Aeeilonnd, D Smres MEE Aesob Sods, amwoYydS meeqes expere Smerhs chater PaowY mado deo samen darelor setstoal 4 cod BaRODeDN wom skies reser Aes skecds wy] mowed, Aeckiootssood BCOR AQTSIOs Aaeteond, .2) RRO Ayseob mdeoriv ackrddch sarke Beards sbey aesn aphscod merony more Bratt Spiteob mdeorid apocdmorbrivd Ast, Aah méconeQ xed GntimdBabY gener — doewtrrient ged xbdodas Dmprriod dgniot eawoyde Yod shat asic Aes Ayre eaghaymen ANOS sebadadg Seeuoadslood pede teem mocbrivah, sidch eds, dmrke song mpmod dowret exdaw Binihsiod & chaos Xaudeond. stoocbaidch mmo / aman dpisead wodeorlert tered woeey meprecdod Aptech mesg xeeds slows ese, edcdetslood wotoawtaw aesa, aidobeandhdd ocd Sexeend echdood mUeonvg wUttohowton sess, SmRprriees sddobenddiond & shoot covtxeond. shed ede woke edetaiath ooyprriy mochiieh, sao aintwen eatdoeat smabsiod xaacd. Wig Ddreded, ayiteod ype. Boo 1. Sderdich mene et adh mmodmedo ambst ay xox sey smpdseend. 2, sobs, mabramrald qamsH Emre adem mBOR. IS EEA, SDgrEHo. oridath Usior Babes marin SHOOT Xog aboAN sedsXeeNd, 3, wBobs, oriatd, citer mop ede, depAry azmood, YB, wobec, doridec GRoR eeblsban ma) smrue mOeR mBpRddeoDA Hosdrsit, sich edd doeurdghs seksobos Wisse mos sgseab BEES BAevived, eadanconen sadfyloyen dercoond, 4, Boda, sea, weld aos), mobecberiss, sigisead axe censs, wortdecd dad Bwhs se ecm FOR. 5. eco we.‘e00-zar0 ‘emai omekaratakagayahca com Hja,8e0b Beige OcieesmOad DIRECTORATE OF MEDICAL EDUCATION eeocnete,, Hore -60 OM Houly ah8/eqy 1a 2019-20 ance: 102.2020 wotged pried eiarD Racemsa BearHe Ayaead sbuenoRDObN “soueont ) mised apyotad Reereciv mewrcevtc ‘eejpreivah, wech air wage ramen owe west easter! a, Karnataka Compulsory Service Training by candidates completed matical CCouses act 2012 & the 2015 rules mae concnyy gaboobsy Saya wuccivsieg wocitert ames eons aROIVOAKAH aiDeOst G0.0B.Z0I9 doch sinetovs RonmaRYS BaUAAEADAR ayoaKd ude Kadawennchys, eb aslo, mer Socide SperuT sipyoecd sompmDaeldy comesetengRaegs ayrybeod Ser seardaved esgorcid sox shir pcb wewo desl Kadgoeied esrabrmandy mow eegpretect NMC Guidlines acnod Houd NOY sixysead OMY AoHHD merie Hasler Rwow exert shot uqadcl shed FoQUoNp wal saad xuciurh RalamzeerDaD wecle ceovst pofeonan uclscidsly Spgsend Rderemebahd wdereds sleatecedt aadagioed eceurluc aby sigh O28 HoBODET ayOERD Ben wows eocie Horie area eapiied ays mBeddho poles onyoriy Feslobey Bdodsian efoinsoss auian ob siigediet eledaatennd. Q Ly fEaxe Saas ses(Satutory Body, established under Karnataka Act No. 34 of 1961) #1616, 2nd Floor, Miller Tank Bed Area, Vasanthnagar, Bangalore - 560 052. Tele : 080-22200888 Fax : 080-22200300 E-mail: karmedi_council@yahoo.co.in_ Website: www: karatakamedicalcouncil.com Dy KARNATAKA MEDICAL COUNCIL DR.KANCHLPRALHADY, —DR.NAGARAJ ANNEGOWDA DR, BRS. MURTHY Presiden Vice President Regisrar Rel. No. encrenyanan Deke yscyaar To DEANY/ PRINCIPAL/DIRECTOR ‘ALL MEDICAL COLLEGES OF KARNATAKA sik, ‘SUB: COMPULSORY REGISTRATION IN KARNATAKA MEDICAL COUNCIL BEFORE JOINING IN YOUR COLLEGE/ HOSPITALS. All Medical Colleges are hereby requested to guide the post Graduate students admitting to your institution from other states to get registered with Karnataka Medical Council compulsorily by getting NOC, from their respective state medical Council. if they are not registered , if they come across any medico legal issues,& they are liable for the same and their Post Graduates Degrees will not be registered with KMC after the completion of their degrees. REGISTRAR Karnataka Medical Councit please avote your KMC reaistration number in your comesoondence