ANNEXURE I MBBS Application Form

ANNEXURE - I
JSS
JS
S UNIVERSITY
(Established under Section 3 of the UGC Act 1956)
JSS Medical Institutions Campus Sri Shivarathreeshwara Nagara, MYSURU – 570 015, Karnataka
Phone: +91-821-25483400/93 ; Fax No.+91-821-2548394Web: www.jssuni.edu.org : registrar@jssuni.edu.in
APPLICATION FOR ADMISSION TO MBBS COURSE
Incomplete Applications will be rejected
Passport size
Photograph attested by
the Dean/Principal/
Gazetted officer
COMED K UGET 2015 Test Score
COMED K Application No
COMED K TAT No
COMED K Rank
Candidate Details (ALL THE ENTRIES IN THE FORM SHOULD BE IN CAPITAL LETTERS ONLY)
1.Candidate's
given in class SSLC/10th
1.Candidate's Name :(As
:
Certificate)
2. Father's/Mother's Name :
3. Gender :
Male
4. Date Of Birth :
5. Caste
Caste / community :
(The
The certificate should be enclosed)
6. Address for Communication:
CITY
PIN :
DISTRICT
STATE
Female
Day
GMGM-
OBCOBC-
Trans Gender
Month
SCSC-
Year
STST-
7. EE-Mail :
8. Telephones :
(STD Code)- (Telephone No.)
Mobile No.
9. Details of Demand Draft :
D. D. No.
Rs. 2,000/2,000/-
Amount in Rs.
Date Of Issue
Day
Month
Year
Name of Drawee Bank
10.
10. Details of Education :
(10+2) / PUC
Name of Board / University
Name of College
Month/Year of Passing :
11. Please enter the percentage of Marks scored in Qualifying exam( Please don't enter % Symbol)
Name of the
Exam Passed
Board / University
Year of
Passing
Class obtained
& attempt
of passing
Medium of
instruction
% of marks
obtained
in aggregate of
all subjects
SSLC/
SSLC/
* Equivalent
10+2 / PUC /
* Equivalent
Any Other
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JSS UNIVERSITY, MYSORE.
12. Please enter the of Marks scored and percentage in Qualifying exam( Please don't enter % Symbol)
Subjects
Maximum Marks
%of
marks
Obtained Score
PCB aggregate %
Physics
Chemistry
Biology
English
DECLARATION BY THE CANDIDATE
1. I, Mr. / Ms. ………………………………………………………… hereby affirm that the information furnished by me in this
application and the enclosures is true. I know that if the information furnished by me is untrue, my seat will be forfeited.
2. I will not indulge in any form of ragging. I know it is a criminal offence and if found guilty, I will be summarily dismissed.
I undertake to make good the loss caused to the college/staff/student or any other person caused by any illegal act of
mine.
3. I am liable to pay the balance of fees calculated for the entire course, in case I discontinue the course or I am expelled
from the college for any reason.
4. I shall abide by all the rules and regulations of the college that may be framed from time to time.
5. In all matters regarding my admission to UG course, the decision of the college is final and binding on me.
Left Thumb Impression of
the applicant.
Place:……………………………
Date:…………………………….
Signature of the applicant
DECLARATION BY PARENT OR GUARDIAN
1. I, Mr. /Ms…………………………………………………… hereby affirm that the information furnished in my Son’s /Daughter’s
/Ward’s application and in the enclosures is true, I know that if the information furnished by my Son / Daughter /
Ward is found to be untrue, my Son’s/Daughter’s/Ward’s seat will be forfeited.
2. I know ragging is a criminal offence and shall take steps to prevent my Son/Daughter/Ward from indulging in it. I also
know that if he / she is found guilty of the offence, he/she will be summarily dismissed from the college. I undertake to
make good the loss caused to the college /staff/student or any other person caused by any illegal act of my
Son/Daughter/Ward.
3. I am liable for payment of the balance of fees calculated for entire course, in case my Son/Daughter/Ward discontinues
the course or is expelled from the college for any reason.
4. I am also aware that once the candidate is admitted to the course, no refund of fees either in full or part there of will be
made, for any reason.
Place: …………………………………
Date: …………………………………
Signature of Parent / Guardian
Declaration to be signed by the Guardian, only in case of both father & mother of the candidate being not present)
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JSS UNIVERSITY, MYSORE.
LIST OF ENCLOSURES TO ACCOMPANY THE APPLICATION FORM:
•
Processing fee of Rs. 2,000/- only by way of DD favouring JSS University Fee
Account, MYSURU, payable at MYSURU along with the documents listed
below.
* Attested copies of the following documents have to be enclosed along with
the application form and kindly arrange the documents in the following order.
1. COMED K - UGET 2015 Score
2. COMED K - UGET 2015 Rank card
3.
COMED K - UGET 2015 Test Admission Ticket (TAT)
4. S.S.L.C./Equivalent examination marks card.
5. P.U.C./Equivalent examination marks card / Proof of having appeared the
PUC II / 10+2 / HSC or equivalent examination. B.Sc.,/Equivalent examination all
the three years marks cards (in case of graduates)
6. Conduct/Character and Transfer certificate issued by the college last studied.
7. Date of birth certificate if not mentioned in the SSLC/Equivalent examination marks
card.
8. Caste / community certificate.(The certificate issued by competent authority)
9. Transfer certificate for Karnataka board candidates.
10. Migration Certificate issued by the Board /University in case of candidates coming
from outside Karnataka State.
11. Six recent, identical passport-size colour photographs with name and date.( In
addition one copy of the photo should be pasted on the application form in the
space provided)
12. Self addressed 3 nos. envelops. ( Size = 10.5” X 4.5” OR 9.5” X 4.5”)
13. Foreign Nationals seeking admission should obtain eligibility certificate issued by JSS
University, MYSURU.
Note:
The prospective candidates are directed to enclose the copy of
COMED – K UGET – 2015 entrance test score, Rank, TAT card and above
mentioned documents along with application before sending to the
University office for registration. Incomplete application will not be
processed.
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JSS UNIVERSITY, MYSORE.