Application No:

ADMISSION TO MBBS/ BDS COURSE 2012-2013 SESSION COMMON APPLICATION FORM SELECTION COMMITTEE , DIRECTORATE OF MEDICAL EDUCATION RANDOM NUMBER : AR No ( To be assigned by the Selection Committee )
------------------------------------------------------------------------------------------------------------------------------------------------------------------1. +2 Examination/ Equivalent Register Number Year and Month 2. Name in Block Letters (Initial at the end ) : ............................................................... 3. Address for Communication : REGISTER NUMBER YEAR MONTH

PIN CODE ... Land line Phone No :.. Mobile No. . 4. Name of Parent / Guardian . :

SPACE FOR PHOTOGRAPH WITH NAME AND DATE ( TO BE ATTESTED BY GRADE A / B OFFICERS OF CENTRAL / STATE GOVERNMENTS) 5. Sex : (Encircle a code) MALE 1 FEMALE 2

6. Nationality : (Encircle a code) INDIAN 1 OTHERS 2

7. Nativity : (Encircle a code) TN OTHERS 1 2

7 a. Details of Education: (Encircle the code which is applicable) Studied from VIII Std to + 2 in Tamil Nadu 1 Studied from VIII Std to + 2 in Other State 2

7 b. If you have completed your plus 2/ equivalent schooling in Tamil Nadu encircle a code: Government Govt.aided 1 2 Corporation 3 Municipality 4 KVS 5 CBSE 6 Pvt. School Others (Specify) 7 8

8. School(s) of study ( Evidence to be produced from the schools studied ): STANDARD STUDIED VIII STD IX STD X STD XI & XII STD/ EQVNT NAME & ADDRESS OF SCHOOL WITH PLACE, NAME OF STATE & PINCODE

9. Date of Birth : DATE MONTH YEAR

10. Community ( Encircle a code ) OC BC 1 2 BCM 2A MBC/DC 3 SC 4 SCA 4A ST 5

11. Caste Code :

12 . Name of the Caste : ..

Refer list of Communities ( For OC use code 500 )

13. Qualifying Examination : (Encircle a code )

13 a. Particulars of passing the Qualifying Examination:

DETAILS REG NO MONTH & YEAR 1st Attempt 2nd Attempt 3rd Attempt

HSE 1

SSCE/ CBSE ISCE 2 3

OTHERS 4

14. Religion with code : 15. Marks obtained in select Science subjects in the Qualifying Examination in the First Attempt only : SUBJECT PHYSICS CHEMISTRY BIOLOGY BOTANY ZOOLOGY TOTAL MARKS ( X+Y) or ( Z + Y) SUBJECT MAXIMUM MARKS MARKS OBTAINED MAXIMUM MARKS MARKS OBTAINED PERCENTAGE OF MARKS Y1 Y2 X Z1 Z2 Z X WEIGHTED TOTAL MARKS Y METHOD OF CALCULATION

Y=

Y1+Y2 2 X

Z= Z 1 + Z 2
2

15. a Marks obtained in the Fourth Optional Subject: 16. Are you undergoing or completed a Professional

Course in Tamil Nadu ? If Yes furnish particulars. If No write not Applicable ( NA) :
NAME OF COURSE MONTH, YEAR FROM TO NAME & PLACE OF COLLEGE

17. a. If claiming for Special Categories, have you applied

in the Form prescribed for Special Category ( Please Tick )

YES

NO

b. If Yes specify the Special Category with code numbers

S.No I II III

Code No

Special Category

(Maximum of three special categories only permissible)

18. a. Educational status of the family (if admitted will you be the

YES

NO

First Graduate in the Family ?) ( Refer Annexure XIV a & b) ( Please Tick ) b. Has your brother/ sister availed first graduate fee concession for studying professional courses.
19. Medium of Instruction : ( Encircle a code ) YES NO

( Please Tick)

ENGLISH TAMIL OTHERS 1 2 3

20. Mother Tongue with code : 21. Occupation of Parent / Guardian ( Encircle a code) :
STATE GOVT CENTRAL GOVT AGRI CULTURE PRIVATE ORGANISATION SMALL TRADE OTHERS

PROFESSIONAL

INDUSTRY

BUSINESS

22. Average monthly income of Parent/ Guardian : ( Encircle a code ):

3000

3001-5000

5001-8000

8001-12000

12001-17000

17001- 21000

21000

23. Civic status of your Native place ( Encircle a code ):

CORPORATION MUNICIPALITY TOWNSHIP TOWN PANCHAYAT VILLAGE PANCHAYAT OTHERS

24.Civic status of your School place ( Encircle a code ):

CORPORATION MUNICIPALITY TOWNSHIP TOWN PANCHAYAT VILLAGE PANCHAYAT OTHERS

25. District Code ( as given in the Prospectus ) :

NATIVE DISTRICT

DISTRICT IN WHICH STUDIED SCHOOL

Signature of Parent / Guardian with Date

Signature of Candidate with Date

DECLARATION BY THE APPLICANT & PARENT

I (Name in Full & in Block Letters) Son/ Daughter / Ward of .. an applicant for MBBS/ BDS course 2012-2013 session hereby solemnly declare that I have not claimed Dual Nativity in this regard and I belong to ...(Community) and subcaste ..I also declare that the information and the statements given in the application, OMR sheet and enclosures are true, correct & complete. I further declare that if it is found otherwise, I will be liable to forfeit the seat and / or be removed from the rolls of the institution at whatever stage of study, I may be, besides making me liable for criminal prosecution. I further declare that I have not claimed the marks obtained in HSE/ equivalent examination under improvement scheme for seeking admission to MBBS/ BDS course 2012-2013 session. I .(Name in Full & in Block Letters) Father/ Mother / Guardian of .. an applicant for MBBS/ BDS course 2012-2013 session hereby solemnly declare that I am fully aware of the above declaration & the particulars furnished are correct. I declare that if it is found otherwise my ward will be liable to forfeit the seat and also be liable for criminal prosecution.

Signature of the Parent/ Guardian

Signature of the Candidate

CERTIFICATE OF NATIVITY IN TAMIL NADU ( Kindly refer Annexure XII in Prospectus for Instructions )

Name:

Application No:.

Certified that ................................................. S/ D/ W of .residing at ................................................................................................................................... an applicant seeking admission to MBBS / BDS course in Government / Self financing Colleges in Tamil Nadu for is a Native of Tamil Nadu.

Signature of Village Administrative Officer Of. In the .. Taluk Of . District

Signature

Name & Designation : Station Office Seal Date : : :

Note :

This Certificate should be issued by an officer of the Revenue Department not below the rank of Tahsildar in the Taluk concerned.

ADMISSION TO M.B.B.S/ B.D.S COURSES 2012 2013 SESSION SCRUTINY FORM 1. Details of Qualifying Exam
Registration Number Passing Month Passing Year

INSTRUCTIONS TO FILL UP SCRUTINY FORM

1. To be filled by the candidates as per the entries made in the application form and returned 2. Use only Blue color Ball Point Pen for ticking and writing 3. Put Tick mark(9) in the correct Gray color boxes 4. Write inside the white box, wherever writing is required
.

2. NAME 3. ADDRESS Paste here firmly your recent Photography 4cm x 5cm Pincode : Mobile : 5. Sex 1. M 2. F 1
6. Nationality 1. Indian 2. Others 7.Nativity
1

1. TN

2. Others

7a. Details of Education 9. Date of Birth 10. Community / 1. OC 4. SC

2
.

7b. Have completed your +2/ equalent schooling in TN, if Yes

/ 2. BC 2A. BCM . MBC 4A. SCA 5. ST

11.Caste Code
13a. Passed all the Subjects of the Qualifying Examination in Attempts No.

2.SSCE/ 13. Qualifying 1.HSC 3. ISCE 4.OTHERS CBSE Examination 15.Marks in Subjects (As Entered in Application Form) Subject Physics Chemistry Biology
.

14. Religion Fourth Option Subject Subject Marks

Botony

Zoology

Maximum Marks Marks Obtained

16. Undergoing /Completed any professional course

.

1. Yes

2. No
.

17.Special Category

1. Yes If Yes?

2. No

18a. First Graduate in Family

1. Yes

2. No

If Yes?
5. B.SC AGRI 6. VETERINARY 7. PARAMEDICAL 8. OTHERS

1. MBBS 2.BDS 3. BE/B.TECH 4. D.I.E.T.

1. Children of Freedom Fighter 2. Children of Ex Servicemen 3. Eminent Sports Person 4. Physically Disabled

18b. My Brother/Sister availed First Graduate fee Concession for Studying Professional Courses

1. Yes

2. No

19. Medium 1. English of Instruction

2. Tamil

3.Others

20. Mother Tongue

21. Occupation of the parent
22. Monthly Income of Parent/ Gaurdian

Civic Status

23. Native 24. School Place Place

25. Disctrict Code

Native District

School District

I sincerely affirm that the information furnished above are true. Station : Place :

Signature of the Candidate with in the box

A.R.No. (For Office use only)

M.B.B.S. / B.D.S. 2012 2013 SESSION

SPECIAL CATEGORY FORM II FOR EMINENT SPORTS PERSONS

Code No Category of Special Reservation 03 EMINENT SPORTS PERSONS

1. Application No (As printed in the Prospectus)

2. Name of the Candidate with Address

..................................... . . . . PIN..

Telephone No: Mobile No: . With STD Code 3. Details of DD enclosed DD No DATE AMOUNT Details of Bank

4. Sports Certificates enclosed Yes 1 No 2

Signature of the Candidate ( For Instructions see overleaf )

Instructions 1. The Special Category form of Sports Quota along with the application should be submitted in person to the Secretary, Selection Committee, Kilpauk, Chennai 600010 with relevant certificates as per Annexure III b. The selection process guidelines are contained in Annexure III a. 2. Tick the relevant box in the outer cover.

3. Candidate should enclose a DD for 100/ - drawn in favour of the Secretary, Selection Committee, Kilpauk payable at Chennai. The Name , Application No & Address should be written on the reverse of the DD. 4. Candidates should enclose an additional self addressed envelope ( 24 X 12 cms) to send the special category counselling call letter. 5. Application without a DD for 100/- and without the relevant sports certificate will be summarily rejected without intimation to the candidate. Table showing the Special Category Code No. , Name and Number of seats Code No. 03 Category Number of Seats 3

Eminent Sportsperson*

* G.O. (st) No . 145 HE (J1) Dept . dt. 16.05.2008

A.R.No. (For Office use only)

M.B.B.S. / B.D.S. 2012 -2013 SESSION

SPECIALCATEGORY FORM I

Code No Category of Special Reservation 01 02 04 CHILDREN OF FREEDOM FIGHTERS SONS & DAUGHTERS OF EX-SERVICEMEN ORTHOPEDICALLY PHYSICALLY DISABLED

1. Application No (As printed in the Prospectus) 2. Name of the Candidate with Address ..................................... . . . . PIN.. Telephone No: Mobile No: . with STD Code

3. Special Category applied for ( Tick the relevant Box) Son/ Daughter of Code 01 Freedom Fighter Code 02 Ex Servicemen Orthopedically Physically Disabled

4. Details of DD enclosed : DD No DATE AMOUNT Details of Bank

5. Special Category Certificate enclosed

Yes 1

No 2

Signature of the Candidate ( For Instructions see overleaf )

Instructions 1. The Special Category form is to be sent along with the application 2. Tick the relevant box in the outer cover.

100/ - drawn in favour of the 3. Candidate should enclose a DD for Secretary, Selection Committee, Kilpauk payable at Chennai. The Name of the Candidate , Application No & Address should be written on the reverse of the DD. 4. Candidates should enclose additional self addressed envelope (s) (23 X 10 cms) to send the special category counseling call letter(s). 5. Candidates should enclose relevant certificates obtained from the competent Authority 6. Application without a DD for 100/- and without the relevant certificates will be summarily rejected without intimation to the candidate.. Table showing the Item No., Code No., Category of the Special Category and number of seats Code No. 01 02 04 Category Son/Daughter of Ex-servicemen* Son/Daughter of Freedom Fighters** Orthopedically Physically Disabled *** Number of Seats 3 3 3 % Total Seats

*G.O. (st) No . 145 HE (J1) Dept . dt. 16.05.2008 ** G.O. (Ms) No . 198 HE (J1) Dept . dt. 30.05.2003 ***3 % of total seats under Single Window System

APPLICATION FORM FOR M.B.B.S/B.D.S. COURSE 2012 2013 SESSION

(TICK Year of Passing +2 Exam

THE RELEVANT COLUMN)

+ Examination Registeration Number

COMMUNITY Code No.

1 2 4

OC BC BCM

MBC/ SC SCA ST DNC

Form No

II 3

SPECIAL CATEGORY NO

YES

From : (Candidates Mailing Address)

To. The Secretary, Selection Committee, Directorate of Medical Education, No. 162, Periyar E.V.R. High Road, Kilpauk, Chennai 600 010

Name :.......... .. .. .. Pincode :.. Phone/Mobile :

Note : Candidates seeking admission under special categories have to submit the special category form along with the General Category

Application in the same cover. Oterwise they will not be considered under special category.