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JAWAHARLAL INSTITUTE OF POSTGRADUATE MEDICAL EDUCATION ANDRESEARCH PUDUCHERRY 605 006

Application Form for Admission to Ph.D. /Fellowship / D.M. / M.Ch. Courses - August 2012-13 Sessions

[Please read the instructions in the Prospectus before filling up the application]

Course Applied for: ________________________________________________________ Code No.:________________(Candidates applying for two courses have to submit separate applications)

1. Name:

(In CAPITAL LETTERS as entered in Degree Certificate)

2. Name of the Parent/Guardian:

Date Month Year

3. Date of Birth:

4. Gender: Male Female (tick : )

5. Indian National: Overseas Citizen of India: (tick : )

6. i) Qualifying examination passed:...........Branch ..

ii) College / University: ..

iii) Year of passing: .

7. Address to which communications are to be sent:

..

...

...

...

Pin Code: .. Mobile No..

e.mail address:.

8. Service Candidate: 1. Yes 2. No (IfYes, NOC from the employer to be enclosed)

9.DD Particulars: Bank.. No DateAmount.(Application without valid Demand Draft shall be summarily rejected)

10. Exam Passed : ICMR/CSIR/UGC/NET/JRF/DBT/DST:

(Applicable only for Ph.D. Candidate)(Enclose the Mark/Grade Sheet)

DECLARATION BY THE APPLICANT

I hereby declare that I am an Indian National / Overseas Citizen of India.

I hereby declare that the information given above is true and correct to the best of my knowledge and belief. I further declare toproduce all certificates in original at the time of admission / Counseling relevant to my claims made in the application. I also agree toforfeit my claim for admission in the event of failure to produce the relevant original certificates. I shall abide by the Rules andRegulations of the Institute.

{

Signature of Applicant in running hand writing

91

Affix your photographNot to be attested

FOR OFFICE USE ONLY

ROLL No. .

A lication No.

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Jawaharlal Institute of Post-Graduate Medical Education and Research (JIPMER), Puducherry 605006

(Candidates are required to fill up in clear handwriting the following details. Affix identical Passport size photographs and enclosed two selfaddressed stickers along with this Hall Ticket at the time of submission of Application Form)

HALL TICKET(Original)FOR D.M.,M.CH., FELLOWSHIP & Ph.D. COURSESDate of Entrance Examination : 22.07.2012 (Sunday) Time: 10.00 AM

Course applied for: Code

Venue of Examination:(for office Use only)

[

CANDIDATE DETAILS

Name of theCandidate:

Date of Birth:

Signature of the candidate

Address ofthe Candidate:

For Office Use:

Regulations relating to the Entrance Exam. are printed overleaf. Professor (Academic)

Jawaharlal Institute of Post-Graduate Medical Education and Research (JIPMER), Puducherry

605006(Candidates are required to fill up in clear handwriting the following details. Affix identical Passport size photographs and enclosed two self

addressed stickers along with this Hall Ticket at the time of submission of Application Form)

HALL TICKET(Duplicate)FOR D.M.,M.CH., FELLOWSHIP & Ph.D. COURSESDate of Entrance Examination : 22.07.2012 (Sunday) Time: 10.00 AM

Course applied for: Code

Venue of Examination:(for office Use only)

[

CANDIDATE DETAILS

Name of theCandidate:

Date of Birth:

Signature of the candidateAddress ofthe Candidate:

For Office Use:

Regulations relating to the Entrance Exam. are printed overleaf. Professor (Academic)

Affix Passport sizePhoto of the candidate

Not to be attested

Appl. No.:

To be filled by Office

Roll No.:

Affix Passport sizePhoto of the candidate

Not to be attested

Appl. No.:

To be filled by Office

Roll No.:

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INSTRUCTIONS TO CANDIDATES

1. The Hall Ticket is purely provisional and is subject to the condition that, if ineligibility is detected at any stage or ifany information provided by you are not found to be authentic on scrutiny and verification, your application will becancelled.

2. Check the particulars e.g. Venue, Roll Number with Web Information and Error(s), if any, should be immediatelyreported in writing to Dean JIPMER, for necessary rectification.

3. Candidates should report at the examination venue latest by 09.45 a.m. No entry will be permitted after 10.30 a.m.

Candidates will be permitted to leave the hall only after close of examination.(11.30 am / 1.15 pm)4. Carry only Hall Ticket inside the room. No candidate will be allowed to take the examination without producing the

Hall Ticket. Do not carry any other article, even envelope of hall ticket into examination hall.5. Ball point pen will be provided by the invigilator in the Hall. Candidates are not permitted to bring their own pen to

the examination hall.6. Do not attempt to give or to obtain assistance of any kind during the examination.7. In the attendance sheet shown to you by the Invigilator, enter the serial number of answer sheet, write your address

in running hand writing and sign against your Roll number only. Affix your left hand Index fingerprint impression inthe respective column of the Attendance sheet.

8. Do not copy or note down questions anywhere during the examination such attempts or removing any page fromquestion booklet will be booked under the Unfair Means Case.

9. Do not fold the answer sheet or leave any smudge on it. The scanner would red it as double marking.10. In the Answer sheet enter Roll number and mark one oval for each question. Sign in the appropriate Box provided in

the answer sheet.

11. Cell phones, pagers, calculators, alarm clocks, earphones are strictly prohibited. No arrangements will be made forany safekeeping by the duty staff of examination venue.

12. In case of candidates losing this hall ticket, they are required to submit a downloaded printout of their Roll no. andvenue details from JIPMER Website www.jipmer.edu.in and an attested passport size photograph and show any oneof their photo IDs in original (school ID card / Driving licence) to the invigilator.

13. Distribution, category and total number of seats are subject to change according to any periodic directives fromSupreme Court of India and or Ministry of Health & Family Welfare Govt. of India.

This Original Hall Ticket must be carefully preserved and produced at the time of counseling and admission also

-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

INSTRUCTIONS TO CANDIDATES

1. The Hall Ticket is purely provisional and is subject to the condition that, if ineligibility is detected at any stage or ifany information provided by you are not found to be authentic on scrutiny and verification, your application will becancelled.

2. Check the particulars e.g. Venue, Roll Number with Web Information and Error(s), if any, should be immediatelyreported in writing to Dean JIPMER, for necessary rectification.

3. Candidates should report at the examination venue latest by 09.45 a.m. No entry will be permitted after 10.30 a.m.Candidates will be permitted to leave the hall only after close of examination.(11.30 am / 1.15 pm)

4. Carry only Hall Ticket inside the room. No candidate will be allowed to take the examination without producing theHall Ticket. Do not carry any other article, even envelope of hall ticket into examination hall.

5. Ball point pen will be provided by the invigilator in the Hall. Candidates are not permitted to bring their own pen tothe examination hall.

6. Do not attempt to give or to obtain assistance of any kind during the examination.7. In the attendance sheet shown to you by the Invigilator, enter the serial number of answer sheet, write your addressin running hand writing and sign against your Roll number only. Affix your left hand Index fingerprint impression inthe respective column of the Attendance sheet.

8. Do not copy or note down questions anywhere during the examination such attempts or removing any page fromquestion booklet will be booked under the Unfair Means Case.

9. Do not fold the answer sheet or leave any smudge on it. The scanner would red it as double marking.10. In the Answer sheet enter Roll number and mark one oval for each question. Sign in the appropriate Box provided in

the answer sheet.11. Cell phones, pagers, calculators, alarm clocks, earphones are strictly prohibited. No arrangements will be made for

any safekeeping by the duty staff of examination venue.12. In case of candidates losing this hall ticket, they are required to submit a downloaded printout of their Roll no. and

venue details from JIPMER Website www.jipmer.edu.in and an attested passport size photograph and show any oneof their photo IDs in original (school ID card / Driving licence) to the invigilator.

13. Distribution, category and total number of seats are subject to change according to any periodic directives fromSupreme Court of India and or Ministry of Health & Family Welfare Govt. of India.

This Original Hall Ticket must be carefully preserved and produced at the time of counseling and admission also