1
MADHYA PRADESH MEDICAL SCIENCE UNIVERSITY, JABALPUR (M.P.)
Form for Enrollment/Eligibility of Under Graduate Course for
ENROLLMENT NUMBER (For University use)
Admission Year 2015
- 16
To
The Registrar
Madhya Pradesh Medical Science University, Jabalpur (M.P.)
Sir,
I request permission to enrol myself at the ensuing Under Graduate course in the batch 2015-2016.
I furnish my details as stated below:1.College Name
2. FACULTY
4. Left Hand Thumb Impression of
the Candidate
3. COURSE CODE
6. Paste (do not
staple) recent
Photograph duly
attested by the Dean/
Principal/ Head of the
Institution.
5. Signature of the Candidate in
running hand, within the box only
Candidate’s Name in Capital Letters (Strictly as per Class XII or Gazette Notification):
FIRST NAME
MIDDLE NAME
SURNAME
7. Date of Birth
Date
Month
Year
8. Gender
Male
9. Category
SC ST OBC
UR
Female
10. Special
Reservation if any 11. Admission Month
Date Month Year
(Specify)
13. FATHER’S/HUSBAND NAME in Capital Letters
12. MOTHER’S NAME in Capital Letters
14. Candidate’s mailing address in CAPITAL Letters only
House no.
Street
State
Indian
Building/ Locality
City
Pin Code
15. Email id of Student
17. Mobile no of student
16. Email id of Father/ Mother (if available)
18. Mobile no of Father/ Mother
19. NATIONALITY
NRI
Foreigner (Specify)
M.P. State
20. DOMICILE
Out of M.P. State If OMPS. Specify State
21. Aadhar Card Number of Student (for Indian Nationals)
22. Details of HSC/CBSE/ISC/ICSE Examination passed
Name of Board
Year of Passing
PCB Marks
Percentage of PCB Marks
English Marks and %
Total Fee Submitted
23. Details of Entrance Examination passed
Exam (AI/DMAT/ Other)
Roll number
Total Marks and %
Rank in Common list
Rank in Category list
24. Fee Submission Detail
Receipt Number
2
25. DECLARATION BY THE CANDIDATE
I……………………………………………………………………………………………………………………..
Son/
Daughter/
of…………………………………………………………………………………………………
Admitted in Course………………………………………..Admission Year………………………………………
in
the
College…………………………………………………………………………………………………………………
hereby declare that above information furnished by me is correct. If any information furnished by me is found
fraudulent/incorrect/untrue at a later date, I am aware that my admission is liable to be cancelled and civil/criminal
action can be prosecuted against me. I am fully aware that the University shall return my application of enrolment
towards non-compliance of documents within a period of 90 days from the date of admission. I have perused
eligibility rules for admission and thereby declare that I am eligible to be enrolled with the University.
I am also aware that late fees shall be attracted towards late submission of eligibility documents as
prescribed by the University.
Date :………………………
Signature of Candidate
I certify that entries made by the candidate in the application form are correct and have been verified from the
original documents. On perusal of documents, it is found that the candidate is eligible for the admission to the
course as per prescribed norms. It is apprised to the candidate to comply-with requisite documents within a period
of 90 days, falling which his/her admission shall be cancelled by the Colleges.
Office
Seal
Signature of the
Dean/Principal
Of the College/Institute
3
Checklist of documents to be submitted by the candidate (Put  whichever applicable)
Sr.No.
Particular of documents
Original
Attested
Photocopy
1
a.
Nationality Certificate issued by District Magistrate/Additional District
Magistrate/Chief Metropolitan Magistrate or
b.
Photocopy of Valid Passport duly attested by Dean/Principal/Director or
c.
Domicile certificate or
d.
Birth Certificate endorsed with Nationality as “Indian” on it.
2
Secondary School Certificate (SSC)
3
Higher Secondary School Mark Sheet/Qualifying Examination Mark Sheet/ (HSC)
4
Entrance Examination Marks Sheet
5
AIPMT/GOI Selection letter (if applicable)
6
Caste Certificate (If applicable)
7
8
Caste Validity Certificate
(It is mandatory to the candidate belonging to reserved category to submit Caste
Certificate duly supported by Caste Validity Certificate & Non-Creamy Layer
Certificate (If Applicable) Failing which proposal will not be accepted)
Valid Non-Creamy Layer Certificate for VJ, NT, OBC, SBC
9
College Leaving Certificate (LC/TC)
10
Copy of Gazette for change in name (IF applicable)
11
Migration Certificate issued by the respective Board/University applicable to
a) Students who have passed HSC examination from outside Maharashtra
b) After passing HSC/Qualifying examination, students who have joined
Any other course for period of more than six months
Affidavit Gap Certificate (made by the student duly certified by Executive
Magistrate/Notarised (if applicable)
Medical Fitness Certificate duly quoted with Registration number (as per the format
prescribed in the Information Brochure by respective Competent Authority)
Physically Handicapped Certificate (as per the format prescribed in the information
Brochure by respective Competent Authority) (if applicable)
Copy of Aadhar Card
12
13
14
15
16
Students admitted in NRI quota required to submit
a. Equivalence Certificate issued by Association of Indian University (AIU)
b. Grade marks/credit point conversion as per Indian marks issued by respective
Board/University
Applicable to post Basic B.Sc. Nursing student only
17
General Nursing Midwifery course (Final Year Mark Sheet only)
18
Valid Registration Certificate issued by respective Council
19
Diploma Certificate issued by respective Council
20
Experience Certificate duly signed by Head of Institute (Applicable to students
admitted in Govt. Colleges)
Note :1.
2.
Place:
Date:
It is mandatory to submit above documents in chronological order with one set of original and one set of attested
Photocopies. However, original documents specified at Sr. No. 11, 12 & 13 to be attached with set of photocopies,
which will be retained by the university.
Status of submission of documents shall be subject to verification by MPMSU office.
Signature of Candidate in running hand
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Annexure - 1
ENROLLMENT/ ELIGIBILITY FEE RECIEPT
(COLLEGE COPY)
2015-2016 Batch
No................................
Date:
NAME OF THE CANDIDATE:…………………………………………………………………………………………………………….
COLLEGE NAME AND CODE:……………………………………………………………………………………………………….
TOTAL AMOUNT OF FEE DEPOSITED ₹______________ ₹ ____________________________________
SIGNATURE OF CANDIDATE
SIGNATURE AND SEAL OF COLLGE AUTHORITY
ENROLLMENT/ ELIGIBILITY FEE RECIEPT
(COLLEGE COPY)
2015-2016 Batch
No................................
Date:
NAME OF THE CANDIDATE:…………………………………………………………………………………………………………….
COLLEGE NAME AND CODE:……………………………………………………………………………………………………….
TOTAL AMOUNT OF FEE DEPOSITED ₹______________ ₹ ____________________________________
SIGNATURE OF CANDIDATE
SIGNATURE AND SEAL OF COLLGE AUTHORITY
ENROLLMENT/ ELIGIBILITY FEE RECIEPT
(COLLEGE COPY)
2015-2016 Batch
No................................
Date:
NAME OF THE CANDIDATE:…………………………………………………………………………………………………………….
COLLEGE NAME AND CODE:……………………………………………………………………………………………………….
TOTAL AMOUNT OF FEE DEPOSITED ₹______________ ₹ ____________________________________
SIGNATURE OF CANDIDATE
SIGNATURE AND SEAL OF COLLGE AUTHORITY
5
FACULTY
1.
2.
3.
4.
5.
6.
7.
8.
9.
MEDICAL
DENTAL
AYURVEDA
UNANI
SIDDHA
HOMEOPATHY
NATUROPATHY & YOGA
NURSING
PARAMEDICAL
CODING OF COURSES
S.No.
FACULTY
FACULTY
CODE
1.
Medical
M
2.
Dental
D
3.
Ayurvedic
A
4.
Unani
U
5.
Siddha
S
6.
Yoga&Naturopathy
Y
7.
Homeopathy
H
COURSE
COURSESPECIALIZATION COMPLETE
CODE
CODE
COURSE
CODE
MBBS (UG)
MD/MS (PG)
Diploma (PG)
M.Ch /DM
Ph.D
Fellowship
00
01
02
03
04
05
00
00-99
00-99
00-99
00-99
00-99
M0000
M0100
M0200
M0300
M0500
M0600
BDS (UG)
MDS
Ph.D
Fellowship
00
01
02
03
00
00-99
00-99
00-99
D0000
D0100
D0200
D0300
BAMS(UG)
MD (PG)
Ph.D
Fellowship
00
01
02
03
00
00-99
00-99
00-99
A0000
A0100
A0200
A0304
BUMS(UG)
MD(PG)
Ph.D
Fellowship
00
01
02
03
00
00-99
00-99
00-99
U0000
U0100
U0200
U0300
BSMS(UG)
MD(PG)
Ph.D
Fellowship
00
01
02
03
00
00-99
00-99
00-99
S0000
S0100
S0200
S0300
BNYS(UG)
MD(PG)
Ph.D
Fellowship
00
01
02
03
00
00-99
00-99
00-99
Y0000
Y0100
Y0200
Y0300
BHMS (UG)
MD(PG)
Ph.D
Fellowship
00
01
02
03
01
02
03
04
H0000
H0100
H0200
H0300
6
8.
Nursing
Paramedical
9.
N
P
BSC (UG)
MSC (PG)
Post Basic Nursing (UG)
Ph.D
Fellowship
00
01
02
03
04
00
00-99
00-99
00-99
00-99
N0000
N0100
N0200
N0300
N0400
Bachelor of Physiotherapy (BPT)
Master of Physiotherapy (MPT)
Bachelor in Medical Lab.
Technician (BMLT)
Post Graduate Degree in Medical
Lab. Technician
Diploma in Medical Lab.
Technician
Bachelor in Human Nutrition
Diploma in Human Nutrition
Bachelor Occupational Therapy
Bachelor of Speech Therapy
Bachelor of X-Ray (Radiographer)
Technician
Diploma in X-Ray (Radiographer)
Technician
Diploma in Homoeopathic
Compounder
Diploma in Unani Compounder
Diploma in Ayurvedic Compounder
Diploma in Pharma (Ayurved)
Diploma in Optometric &
Refraction
Diploma in Opthalmic Assistant
Diploma in Microbiology
Technician
Diploma in Blood Transfusion
Technician
Diploma in Biochemistry
Diploma in Dialysis Technician
Diploma in Perfusionist Cardiac
Surgery Technician
Diploma in Anasthesia Technician
Diploma in C.T.M.R.I. Technician
Diploma in Cath. Lab. Technician
Diploma in Gamma Camera
Technician
Diploma in Dental Hygiene
Diploma in Dental Mechanic
00
01
02
00
00-99
00
P0000
P0000
P0300
03
00
P0300
04
00
P0400
05
06
07
08
09
00
00
00
00
00
P0500
P0600
P0700
P0800
P0900
10
00
P1000
11
00
P1100
12
13
14
15
00
00
00
00
P1200
P1300
P1400
P1500
16
17
00
00
P1600
P1700
18
00
P1800
19
20
21
00
00
00
P1900
P2000
P2100
22
23
24
25
00
00
00
00
P2200
P2300
P2400
P2500
26
27
00
00
P2600
P2700