GOVT. DENTAL COLLEGE AND HOSPITAL, JAMNAGARGUJARAT (INDIA)

Phone: (O) 02882550369(PBX) 0288 2ss03s2

Fax : 0288 2550369

Navagam GhedJamnagar.361 008

Dtt'l'AName of the student

Native State

Adm. Memo no. & Date

Caste &Catesorv (OP/SC/ ST/SEBC)Total Marks in Sci. sub. as perHSC MarksheetName & Address of the school(last studied)Birlh Date & Place (as perschool leavins eerti.)Name of parents ( Father andMother)Residential Address withPhone no.

Name & Add. Of localguardian (if any)

Date of Adm in coileseHostel Facilitv required. Yes / NoDate of Adm. in hostelHobbies

No student is allowed to go to picnic personally or collectively. A prior writtenpermission of the Dean is a must after which the warden will allow such activities.In daily routine, hostel warden's instructions should be scrupulously followed.Any indiscipline or violation of rules can result in termination of hostel admission.I agree to abide by the aforesaid rules.

STUDENT PERSONAL

Affix your recentpassport sizephoto here

Signature of Parent/ Guardian:Dean,

Govt.Dental College & HospitalJamnagar

Student's Signature:Date:Place: Jamnagar

D:WISHAL KHETIYA - l\Admission form\Student personal details form.doc

GOVT. DENTAL COLLEGE AND HOSPITAL, JAMNAGARGUJARAT (rNDtA)

Phone: {O} 02882550369(PBX) 0288 zss03s2

Fax : 0288 2550359

Navagam GhedJamnagar. 361008

(FOR OFFTCE USE ONLY)

To,Accounts Branch,

Gov. Dental College & Hospital,Jamnagar

Please accept ttre tottowing fees from Mr. /Miss.for admission to first B.D.s. course in this college as per admission orderno... .. . ... dated.Caution money deposit

(Rs. 1000.00)

1000.00

Library fee

(Rs 10.00)

10.00

Hostelfees

(Rs. 1200.00 per year)

1200.00

Tution fees

(Rs. 4000.00- for AIPMT students only)

Others

Total fees

Dean,Govt. Dental College & Hospital,

Jamnagar.To,

Std. sectionReceived fees as stated above via receipt no. ... ..... datedSign:

Acc. Branch, G. D. C.H., Jamnagar

D:\VISHAL KHETIYA - 1\Admission form\.Fees order.doc Page L

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Government Dental College & Hospital, Jamnagar. '

Form For Application For The Girls And Boys Dental Hostel

1. Name:-(Surname) (Name) (Father' name)

2. Present Address :-

3. Permanent Address :-

4. Relationship With Guardian (lf Any)

5. Guardian'name

& Address :-

6. The college term for which application for :-

7. Telephon e / Mo. No. Student,Mother, Father, Brother,sister

Signature of applicant :-

Note :-The applicant should state clearly if the guardian is resident in Jamnagar.

The collage term :-

L.

2.

3.

4.

WARDENGirls and Boys Dental Hostel

Government Dental College & Hospital,Jamnagar.

Personal Detail's of student who got admission in B'D.S' Course during the

Year 200 - 200 .During the term commencing from """"""""j""""'

. PHOTO

l-. Name :-2. Date Of Birth :-

3. Father Name & Address :-

4. Father'sOccu Pation :-

& Address, Contact No.

5. Local Address Of Guardian(lfany)

6. Total Marks Obtained in Science subject :-

7. Date of Admission in'college :-

8. Date of Admission in Hostel :-

9. Reserved in ( if anY )

( o.M./s.c./s.r./sEBS/CBSEc)Date :-Place :- Signature of Student

No student is allowed to go to picnic in personal or collectively, first the written

permission of Dean should be obtained and then the warden will allow prior permission

ls a must.ln daily routine, the hostel superintendent's instruction should be scrupulously

Followed. And indiscipline behaviour or violation of hostel rules will be reselted in

Termination of hostel admission.

I abide by the dforesaid rules and regulation of hostel

Signature of parents :-

Date :-

Signature of Student :.

Date :-

Ssursstrs UniversityRe-Accredited Grade '8, by NAAC (CGpA 2.93)

Enrollrnent Forrn

Frovisional Eligibi!ity Certif!cate Details

Passine Month:Total Marks;

Obtained t\/larks:School Narne :

Scho,:l Completion year:

School Enroll Date:Othen Courses done after HSC:

Higher Secondary Subject Details

Attach Your

Fassport Size

Photograph

with Stapler or

a pin only

Board NameProvisiona I Eligibility Certi.No: Elieibility Certi.Date:Transfer Certi.No: Transfer Certi.Date :

General Details

FATHER'S/H USBAND NAM E:

i_y_.9c/qv:E9_cl9!9!Date of Birth:NationalityResidential address:

Pin code

Mobile/Fhone No.

District

ls Physically Handicap: yes/ NoDetails of Frrevious ExamHSC Seat No.Passing Year:Atte rn pt:

Percentage

School Completion monthSchool Leave Date:

0btained Manks

c:\Documents and settings\abc\Desktop\saurastra University Enroll New.docx Page I of I

GAZETTE OF INDIA. PART III- SEE. 4. EXTRAORDINARY.ANNEXURE:I PART- I

UN DERTAKING BY THE CANDIDATE/STUDENTL' l' ------------ - s/o.D/o. of Mr./Mrs./Ms. -----_______ __have

;il:iti:t read and fullv understood the law prohibiting ragging and the directions of the

supreme court and the centrar/state government in this regard.2 I have received a copy of the DCI iegulations on the curbing the menace of raggingin Dental colleges, 2009 and have carefully gon" tf..,rorgfit.3 I hereby undertake that' I will not indulge in any behavior or act that may come under the definition ofragging.

. I will not partipipate in or abet or propagat ragging in any form.' I will not hurt anyone physically or psychologiiitry o. cause any other harm.

,1.,.' nuruoy agree that if found guirty of any ,rp.J oi ir*s'nr, r may be punished as per

Provisions of the DCI regulations mentioned above and /or as perthe law in force.

irrr,r",ljjleby affirm that r have not been expeted or debarred from admission bv any

Signed this ------ -day of*_ ________month of__________________year

2.

3.

Signature of student

ANNEXURE _I PART- IIUNDERTAKING BY THE PARENT / GUARDIAN

l,-------------_F/O.M/o. G/o_

_________ havecarefully read and fully understood the law prohibiting ragging ,.o,n.ilr..ion, otthe hon'ble supreme court and the central/state gouuinr".nt in this regard as wellas the DCr regurations on curbing the menace of ragging in dentar coileges. 2009.I assure you that my son/daughterlward wiil not inl"ure". in ,ny act of ragging.I hereby agree that if helshe is found guirty of any ,rpJ.t of ragging, he/she may bepunished as per the provisions of ttre oct regulationsmentioned above and/or asper the law in force.Signed this -- day of:--------------month of______________year

Signature ofParent / guardian

Name: Address:

FORM OF CERTIFICATE

MEDICAL CERTIFICATE OF EXAMINATION OF A CANqIDATE FOR ADMISSION TO

MEDICAL & PARAMEDICAL COURSES

I hereby certify that I have examined Shr/ Kum/ Smt..'....""

....., a candidate for admission to Medical/Paramedical Course and cannot discover that

he/she has any disease, constitutional weakness or bodily intirmity except

I do not consider this a disqualification .for admission to the Medical/Paramedical course. Hislher age,

according to his/her own statement, is ..............."....years and appearance is '.....'..'..". years.

Mark of ldentification: -

lmpression of Left thumb

('1) Signature

(2) FullName

(3) Qualification (Minimum M.B.B.S,)

(4) Flegistration No.

Date : / /20

UNDER TAKITSG

,, I hereby agree to coniorm to the rules and regulation at present in force or that may hereafter be made for

governance of Medical and paramedical courses and I undertake that during such course, I will cio noihing either inside

or outside the college that will interfere with the orderly governance and discipline. I am also aware that ragging is banned

and if found guilty, I shall be liable for cancellation of admission and punishment as per rules";

Date:

Place: Signatur,e of the Candidaie Signature ol the ParenV Guardian