COMPUTER FORM SESSION JULY 2011 CLOSING DATE FOR RECEIPT OF APPLICATION : 9-4-2011
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH
APPLICATION FOR ADMISSION IN MD/MS/ MDS/PhD/ DM/MCh/HOUSE JOB ORAL HEALTH SCIENCES/MHA COURSES
Roll No.
IMPORTANT INSTRUCTIONS:1. Please read the prospectus and the instruction given in
prospectus carefully before filling this form. 2; Use blue or black ball pen for filling this form.
3. Tick (a) in the appropriate box against columns 1, 2, 6, 7, 10 d. The change of category
at any stage will not be permitted. (To be assigned by office)
1. Course applying for (Tick (a) in the appropriate box) MDS/ 2. Category Schedule Schedule Rural Area Ortho. Phy Sponsored/ Foreign
MD/MS MHA Ph.D DM M.Ch House Job General OBC Caste Tribe Services Handicaped Deputed National
3. Subject Choice (To be filled by DM/M.Ch/Ph.D & Foreign National (MD/MS) candidates only)
4. Full Name of applicant (In CAPITAL Letters). Please don't write Dr./Mr./Mrs./Ms. before names.
5. a) Father's/Husband's Name (In CAPITAL Letters)
b) Mother's Name (In CAPITAL Letters)
Address For Communication (Please do not repeat your name and father's name)
...........................................................................................................................................................................................................................................................................
...........................................................................................................................................................................................................................................................................
City
...........................................................................................................................................................................................................................................................................
Pin Code Phone No. Mobile No.
6. Sex 7. Nationality 8. Date of Birth 9. Have you already done any PG
Degree Course? YES NO
Male Female Indian Others
Date Month Year (To be filled by the applicants
for MD/ MS/ MDS/House Job (OHS) only)
10. (a) Name of the Institution/University from which examination passed (d) Qualifying Examination Subject/Discipline in PG degree course
( ) in the propriate box (to be filled in by DM/M.Ch/Ph.D Candidates only)
Eqiv.
(b) Month & Year of Admission MBBS BDS MSc to MSc MD MS
MONTH YEAR
(e) Total Marks in 1st+2nd+3rd (4th, if any) Professional / Univ. Examination
(c) Month & Year of passsing the examination Maximum Marks Marks obtainod Percentage
MONTH YEAR
Th H T O Th H T O
11. (a). Date of starting Internship (b) Date / Expected date of completion of Internship (c) No. of days
Date Month Year Date Month Year
12. (i) Attempts made during MBBS/BDS (ii) Attempts made during MD/MS 13.) Date of Registration
(for DM/MCh Courses only) D D M M Y Y Y Y
_________________________ _________________________
14. Medical / Dental Registration No. 16. SIGNATURE OF THE CANDIDATE
a) Permanent b) Provisional (Use Black Ball Pen Only) For Office use only
Declaration
I have carefully read the instructions given in the prospectus. I hereby solemnly and sincerely affirm that the statements made and the information furnished by
me with application form are true and correct. If however, it is found that any information furnished herein is fraudulent, incorrect or untrue in material particulars, I realize
that I am liable to criminal prosecution and my selection and admission to the course is liable to be cancelled.
Date:- Signature of the Candidate
APPLICATION FORM SESSION JULY 2011 CLOSING DATE FOR RECEIPT OF APPLICATION : 9-4-2011
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH
APPLICATION FOR THE ADMISSION IN MD/MS/ MDS,Ph.D, DM/M.CH/
HOUSE JOB ORAL HEALTH SCIENCES/MHA COURSES Roll No.
IMPORTANT INSTRUCTIONS:1. Please read the prospectus and the instruction given in
propectus carefully before filling this form. 2; Use blue or black ball pen for filling this form.
3. Tick (a) in the appropriate box against columns 1, 2, 6, 7, 10 d. 4. The change of category
at any stage will not be permitted. (To be assigned by office)
1. Course applying for (Tick (a) in the appropriate box) MDS/ 2. a) Category Schedule Schedule Rural Area Ortho. Phy Sponsored/ Foreign
MD/MS MHA Ph.D DM M.Ch House Job General OBC Caste Tribe Services Handicaped Deputed National
3. Subject Choice (To be filled by DM/M.Ch/Ph.D & Foreign National (MD/MS) candidates only). For DM/M.Ch./Ph.D Courses, whether applied in other subject, mention
5. Full Name of applicant (In CAPITAL Letters) Please don't write Dr./Mr./Mrs./Ms. before names.
6. a) Father's/Husband's Name (In CAPITAL Letters)
b) Mother's Name (In CAPITAL Letters)
7. Sex 8. Nationality 9. Date of Birth 10. Have you already done any PG
Male Female Indian Others Degree Course? YES NO
Date Month Year (To be filled by the applicants
for MD/ MS/ MDS/HouseJob(OHS) only)
11. Details of qualifying examination passed (d) Qualifying Examination Subject/Discipline in PG degree course
(a) Name of the Institution/University (a) in the propriate box Equiv. (to be filled in by DM/M.Ch/Ph.D Candidates only)
MBBS BDS MSc to MSc MD MS
(b) Month & Year of Admission
WHEATHER PASSED FINAL SEMESTER YES OR NO _______________________
MONTH YEAR
(e) Total Marks in 1st+2nd+3rd (4th, if any) Professional / Univ. Examination
Maximum Marks Marks obtainod Percentage
(c) Month & Year of passsing the examination
MONTH YEAR
Th H T O Th H T O
12. (a). Date of starting Internship (b) Date / Expected date of completion of Internship (c) No. of days
Date Month Year Date Month Year
13. Name of College/University from which MBBS/BDS/MD/MS passed 14. (i) Attempts made during MBBS/BDS _________________________
(ii) Attempts made during MD/MS _________________________
Whether recognised by Medical Council of India ? YES or NO ___________ (for DM/MCh Courses only)
15. Medical / Dental Registration No. c) Date of Registration
a) Permanent b) Provisional D D M M Y Y Y Y
16. Ph.D Registration under which category applied ? 17. PHOTOGRAPH 18. Ph.D under which category applied
i) For the grant of fellowship from the Institute. i) MEDICAL
ii) Research Scheme employee. iI) NON-MEDICAL
Paste
Passport Size
iii) In Service candidate of the Institute. coloured Photograph iii) SOCIAL BEHAVIOUR SCIENCES
with
Name and Date 19. SIGNATURE OF THE CANDIDATE
iv) Sponsored/Deputed Candidate
v) On the basis of Net fellowship by UGC, JRF by
ICMR/CSIR etc. within two years
APPLICABLE FOR DOWNLOADED APPLICATION FORMS
BANK DRAFT NO...........................................................................................in favour of Director , PGI , Chandigarh, Date of issue................
Bank Name/ Branch.....................................................................................................Amount Rs .....................................................................
(Attach DD for Rs.1000/- for Gen./OBC/OPH, Rs.800/- for SC/ST Candidates)
Please write your name & address on the back side of draft.
20. Address :
A) Permanent Address : B) Corresponding Address :
_______________________________________________________ _______________________________________________________
_______________________________________________________ _______________________________________________________
_______________________________________________________ _______________________________________________________
_______________________________________________________ _______________________________________________________
Contact/Mobile No.: ______________________________________ Contact/Mobile No.: ______________________________________
E-mail: _________________________________________________ E-mail: _________________________________________________
21.State/Union Territory to which you belong : _______________________________________________________________________
22. Are you employed if yes, give the following detials
a) Date of Joining as regular service : __________________________________________________________________________
b) Nature of job : __________________________________________________________________________
c) Name of the Institution/Hospital Govt./
Semi Govt./ Pvt. : __________________________________________________________________________
d) Designation : __________________________________________________________________________
e) Pay Scale : __________________________________________________________________________
f) Name of employer : __________________________________________________________________________
23. Are you being sponsored/deputed by your
employer? if sponsored, the application
must be accompanied with sponsorship,
deputation certificate in the form printed
at Annexure 'D' : ____________________________________________________________________
24. Have you any contact person/guardian in
Chandigarh. If so, mention his/her address
Telephone No., If any. : _________________________________________________________________________
25. To be filled in only by applicants for Ph. D. Programme
Details of Experience/Employment/Specialized Training/Senior/Junior Residency/Demonstratorship/Fellowship after Graduation/Post Graduation
Name of the Hospital / Institution Position Heid Period
From To Nature of duties
26. Detail of Research Experience
Name of Project on which worked/working Duration Proof at encl. No.
Year Month Days
PUBLICATION (INTERNATIONAL/LOCAL INDEXED)
27. Applicable for inservice candidates only: (To be filled applicants for Ph.D Programme)
a) Please indicate your Research Publications (atleast Three Research Publications are required) during the three years immediately preceding the date of your
application in indexed Indian/Foreign journals in the concerned area and in related field of research either as a primary author or a co-author.
_____________________________________________________________________________________
_____________________________________________________________________________________
b) Please also indicate your Regular Continuous service at PGI, Chandigarh. (The individual should be a regular employee of the Institute and should have
rendered a minimum five years continuous services at the Institute).
_____________________________________________________________________________________
_____________________________________________________________________________________
INTERNSHIP CERTIFICATE
(To be submitted by the candldate whose Internship is complete or likely to be completed by 30th june/31st Dec for July & Jan session repectively.)
Certified that Dr. _____________________________________________has undergone/presently been undergoing 12 -months compulsory
Rotating Internship Training at ____________________________________________________________________college which started
on __________________and has completed or is likely to be completed on _______________________
Place :______________
Date :_______________
Signature & Seal of Dean/Registrar/Principal/
Medical Superintendent of the Institution from
where the candidate has undergone or is undergoing internship.
ATTEMPT CERTIFICATE - I (For MD/MS/MDS/House Job/MHA Courses)
Candidate may attach the photocopy of attested certificates issued by the Medical College/Institute
Certified that Dr. ______________________________________________son/daughter of Sh. _____________________________________
_________________________________________ has passed professional examination of the MBBS/BDS course from __________________
_____________________________________________________________________________________________as per details given below:-
Examination Month Year in Attemped at which passed.
which passed
1. First Professional _______________________________ _______________________________
2. Second Professional _______________________________ _______________________________
3. Third Professional _______________________________ _______________________________
4. Final Professional _______________________________ _______________________________
It is certified that MBBS/BDS degree of this Medical/Dental College is recognized by the Medical Council/Dental Council of India.
Signature & Seal of Dean/Registrar/Principal/
Medical Superintendent of the Institution from
where the candidate passed MBBS/BDS.
ATTEMPT CERTIFICATE - II (For DM/MCh Courses)
Certified that Dr. _____________________________ son/daughter of Sh. _______________________________________________
has passed the MD/MS examination from the Institute / University in the subject of _____________________ in the ____________________
________________ attempt(s).
It is certified that the above said MD/MS degree of the Institute/University is recognized by Medical Council of
India.
It is further certified that the degree of MD/MS of College/Institution in the subject of
_________________________ awarded to him/her is recognized by the Medical Council of India as per their letter
No. ________________________
A photocopy of the same is enclosed.
Signature _______________
Station ____________________
Designa tion ______________
Date ___________________
Official Seal _______________
Note : 1. Deletion /alteration of any word in the above certificate will lead to rejection of the application summarily
and no intimation will be sent to the candidate.
2. In case a photocopy of the letter from the Medical Council of the India regarding recognition of Postgraduate Degree, College/
Institution is not enclosed, the application shall not be considered.
DECLARATION BY CANDIDATE
1. I hereby declare that the application has been filled in my own handwriting and all statements made in it are
true, complete, and correct to the best of my knowledge and belief and nothing has been concealed. In the event
of any statement being found false or incorrect or any ineligilbitly being detected before or after the selection, action such
as removal of my name from the rolls and / or other action as may be considered necessary can be taken
aganist me.
2. I also declare that I have carefully read the contents of the Prospectus in respect of the course applied for by
me and undertake to abide by the provision contained therein.
3. I further declare that I fulfil all the eligibility conditions regarding educational qualification, experience etc.
prescribed by the Institute for admission to the course applied for by me.
4. If selected :
(a)I agree to work on whole time basis:
(b)I shall not engage myself in private practice or part time job during the period.
(c)I shall not draw any pay, fellowship or any kind of monetary assistance from any other sources, if I am
allowed emoluments by the Institute.
Place __________ (______________________)
Date ______________ Signature of the applicant
DECLARATION BY THE FATHER/GUARDIAN OF THE APPLICANT
I hereby declare that I shall be responsible for timely payment of all dues payable to the Postgraduate Institute
of Medical Education & Research, Chandigarh in respect of my son/daughter/ward(name____________________)
during the period of his/her stay at the institute and until their dues are cleared.
Address _____________________________________ ( )
Signature
___________________________________________ Relationship to the applicant)
ENDORSEMENT BY THE EMPLOYER, IF THE APPLICANT IS IN SERVICE
No........................... Date ......................
Forwarded to the REGISTRAR, Postgraduate Institute of Medical Education and Research, Chandigarh for
consideration. The undersigned has no objection to the applicant of Dr. ______________________being considered by
the Institute for the course applied for by him/her and if selected, he/she will be relieved within, the prescribed time
limit. The applicant is “sponspored /deputed or not sponsored /deputed by us and the sponsorship/deputation -
certificate is enclosed.
Address ___________________________________ Signature of employer
__________________________________________
with official seal
*Strike out whichever is not applicable
DECLARATION TO BE SIGNED BY OBC CANDIDATES ONLY
I......................................................................................................son/daughter of Shri.................................................................
...............................................................................resident of village/town/city...............................................................................
district..........................................................state.............................................................................................................................
(certificate enclosed) hereby declare that I belong to the ..............................................................................................community
which is recognized as a backward class by the Govt. of India for the purpose of reservation in services as per orders
contained in Department of Personnel and Training Office Memorandum No. 36012/22/93-Esstt(SCT)dated 8-9-1993. It is
also declared that I do not belong to the persons/sections (creamy layer) mentioned in coloumn 3 of OM NO. 36012/22/93-
Estt (SCT) dated 08-09-1993 and modified vide Govt. of India Department of Personnel and Training OM NO. 36033/3/2004-
Estt (Res) dated 09-03-2004
Place .............................. (Signature of applicant)
Date ............................... (in running handwriting)
Note:- The closing date for receipt of application will be treated as the date of reckoning for OBC status of the candidate
and also for assuming that the candidate does not fall in the creamy layer.
[ TO BE FILLED BY APPLICANTS FOR Ph.D PROGRAMME ]
CERTIFICATE IS APPLICABLE TO THE CANDIDATES WORKING
UNDER THE INVESTIGATOR OR THE RESEARCH SCHEME
SANCTIONED IN PGI
Certified that Sh/Ms __________________________________________________________________________
Son/daughter of Sh. _____________________________________________________________ who is applying for the Ph.D
programme of Postgraduate Institute of Medical Education and Research, Chandigarh is working under me since
______________________________________ as research empolyee in the research scheme entitled:-
The research Project under which he/she is working will continue for a minimum period of three years. I have no
objection to his/her application being considered for Ph.D programme at PGI, Chandigarh.
His/her work and conduct are satisfactory
Signature of Investigator of the Research Scheme
___________________________________
(Name in Block Capital Letters)
Designation _______________________
Official Seal________________
RECOMMENDATION OF HEAD OF DEPTT.
APPLICATION MUST BE TAGGED PROPERLY & ALL THE ENCLOSURES MUST ACCOMPANY
THE APPLICATION IN SEQUENCE AS PER THE ENCLOSURE LIST GIVEN BELOW
Documents Enclosure No.
1. Attested copy of Matriculation / Higher Secondary _________________________
Certificate Showing Date of Birth
2. Attested copy of Certificate of passing MBBS/BDS/MSc./MA/ M Pharma _________________________
examination
3. Attested copy of Certificate of passing MD/MS examination _________________________
4. Internship completion certificate (who possesses MBBS/BDS Qualification) _________________________
5. Attempt certificate I and II signed by Principal / Dean / Registrar _________________________
(As Applicable)
6. Attested copy of Certificate of permanent Registration with _________________________
Central / State Medical Registration Council / Dental Council of India
7. Attested copies of following Certificates
(See performas in Prospectus) whatever applicable _________________________
i) Caste Certificate in Prescribed Form
SC/ST (Annexure 'A' (in Hindi/English Script)
ii) OBC Certificate (Annexure 'B')
iii) Rural Area Certificate (Annexure 'C')
iv) Sponsorship Certificate (Annexure 'D')
v) OPH Certificate
8. Attested copy of certificate of the character and conduct from the
Institution last attended. _________________________
9. Two self addressed envelopes of size 10x23 cms. Rs. 10/- Postage stamp
on each envelope for use by this office for sending interview letter etc. _________________________
10. Attach Demand Draft for downloaded Application forms as per fee
charges given below : _________________________
MD/MS, For General OBC, OPH : 1000/-
PhD (General) : 1000/-
MD/MS/PhD (For SC/ST) : 800/-
DM/MCh (Price for all Category) : 1000/-
IMPORTANT NOTE
In case any candidate is found to have supplied false information of certificate etc. or is found to
have concealed or withheld some information in his/her Application Form, he/she shall be
debarred from admission.
Any other action that may be considered appropriate by the Director of the Institute may also be
taken against him/her which may include criminal prosecution.
Place _____________________________
Date _______________________________ Signature of the candidate
No. of Enclosures : ___________________
9
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH,
CHANDIGARH - 160012
SELECTION OF CANDIDATE FOR MD/MS, DM//MCh, MHA, Ph.D, MDS/HOUSE JOB (ORAL HEALTH) COURSES
Roll No.
Session July 2011 ADMIT CARD
1. Category_________________ (For office use)
2. Examination Centre: Chandigarh Please paste
here a
Passport size
3. Name of the Candidate_____________________________________________ coloured
photograph with name
& date attested by the
Gazetted Officer
4. Specimen signature of the candidate___________________________________
The photograph along with the specimen signature are affixed thereon to the selection test for
MD/MS, DM/M.Ch.,MHA, Ph.D, MDS/House Job (Oral Health Sciences) mentioned above.
REGISTRAR
Postgraduate Institute of Medical
Education & Research,Chandigarh.
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH,
CHANDIGARH - 160012
SELECTION OF CANDIDATE FOR MD/MS, DM//MCh, MHA, Ph.D, MDS/HOUSE JOB (ORAL HEALTH) COURSES
Session July 2011 Candidate’s Attendence Sheet
Roll No.
(For office use)
1. Category_________________
Please paste
here a
2. Examination Centre: Chandigarh Passport size
coloured
photograph with name
3. Name of the Candidate____________________________________________ & date attested by the
Gazetted Officer
4. Specimen signature of the candidate_________________________________
(Nothing to be written below this line by the candidate), to be filled in at the Examination Centre only
Date and Time Signature of candidate Signature of Invigilator
( to be signed in Examination Hall)
