Willing for next round- Yes/No
Bankura Sammilani Medical College, Bankura.
Application for admission to Post Graduate Medical Degree/Diploma 2024-2025 Course
APPLICATION SHOULD BE FILLED IN BY THE CANDIDATE.
1 AIQ Rank……………… State Rank………………..
2.Date of counseling…………….. Mobile No…………... Space for Photo
Colour
3.Course…………………………. Percentile Score …………………..
4.Email- Date of Admission………………….
5. Exam. Name -……………… with Roll.No……………….
1.Name in full(in Block letters):-
2.Father’s/Husband’s Name:-
3.Name,Occupation & address of guardian(if other than father)
4. Permanent address with contact No:-
Block/Municipality:- Dist:- State:-
Pin:-
5.Nationality :- (6) Sex:- (7) Date of Birth:- (8) Blood Group:-
9.Marital Status:- 10. Whether you are belonging to SC/ST/PH/OBC :- a) Yes (b) No
(mark with a tick(/) in the boxes which is applicable)
11. (a) Are you in W.B.H.S:- (i) Yes (ii) No Gross Salary-
(b) Are you in W.B.M.E.S.:- (i) Yes (ii) No Gross Salary-
If so, state (mark with a tick(/) in the boxes where applicable:-(i) Regular (ii) AD-HOC
12. If in other service, give details :-
13. Name of the University where from obtained M.B.B.S degree.:-
14. University Registration No…………… of…………. University…………………
15. Permanent/Temporary Medical Registration No. …………………Year……………
With the name & Medical Council……………………………………………………
Admission Fees:- Rs- 2000/-
Tuition Fees :- Rs- 6000/-
Caution Money :- Rs- 10000/-
Total Rs:- 18000/-
Contd.Page:-2
Page:-2
16.Academic Qualification(S) :- Details of Total marks in the MBBS Examination.
MBBS Duratio Name of Month & Marks Percentage Total No. No. Prize/ Name
Prof. n the year Obtained Of Marks Of time Of Medal & of
Wise Of University Of Appearing failure(s) Distinction College
Course Admission Including .
One in
Which
Passed
1St
Prof.
2nd
Prof
3rd
Prof.
Part-I
3rd
Prof.
Part-II
MBBS
Or any
Other
Course
.
17. Summary of academic Record:- Statement of total marks obtained in the MBBS Exam.
(All the Prof. Exam. taken together)
Total marks for which Total marks obtained Percentage of Any other relevant
the applicant was by applicant marks obtained information
examined by
the applicant
18. Have you passed 1st.2nd & 3rd. prof. MBBS Exam.in first attemp ? Yes/No
If not, state in the specific coloum, how many attempt(s) you have made to clear the
examination(s).
i) 1st Prof.MBBS. ……………….. attempt(s) (ii) 2nd Prof. ………………….attempt(s)
(iii) 3rd Prof.(Part-I) ……………… attempt(s) (iv) 3rd Prof.(Part-II) ………attempt(s)
(to be supported by a certificate from the Head of the Institution)
19.Completion date of Internship/PRCA training with name of the Institution ……………….
20.Are you at present registered for any Post Graduate Diploma/Degree course including
Ph.D. of any University? If so, give Particulars:-
Contd.Page:-3
Page:-3
21. Have you applied for admission or been admitted to any other course in any institution
during this session?
I do hereby declare that all the statements made by me in this application (including
additional particulars) are true, complete and correct to the best of my knowledge and below
I do hereby submit attested of all documents as mentioned in my application.
In case it is detected at any point of time that any of the statements made by me in this
applications involves suppression of distortion of truth or that the application is not supported
by any of the relevant documents as mentioned in this instruction for admission shall be
cancelled without further reference to me.
I shall be bound to accept the stipulation laid down by the University for the purpose of
admission to the Degree/Diploma course for the session.
-------------------------------------------------
Dated:- Signature in full of the Applicant
Permanent Address:-
Block/Municipality:- Dist:- State:-
Pin:-
DECLARATION IN RESPECT TO ADMISSION ON POST GRADUATE
MEDICAL DEGREE/DIPLOMA OF THEBUNIVERSITY OF CALCUTTA BY
CANDIDATES WHO ARE NOT IN ANY SERVICE IN ANY CAPACITY IN ANY
ORGANISATION.
I do hereby declare that I am not in West Bengal Health Services/ West Bengal Medical
Education Service, not in service including Housemanship. In case of suppression of
distortion of facts as declared by me my admission to the course, if detected, will be liable to
the cancelled outright.
-------------------------------------------------
Dated:- Signature in full of the applicant.
N. B.- Following details must be mentioned for refund of fees (in case of upgradation).
( bank details must be the same from which the fee has been deposited.)
1. Name of the Beneficiary
2. Beneficiary Bank & Branch
3. Beneficiary Bank Account No.
4. IFSC Code
5. E-mail id.
PG Admission 2024-25
The following documents are required for online reporting for verification by the
College authorities.
1) Allotment Letter
2) Rank Card
3) Score Card
4) NEET PGAdmit card
5) Age Proof
6) All MBBS Mark Sheets
7) H.S Mark Sheet
8) Internship Completion Certificate
9) MBBS Degree Certificate
10) Permanent Registration
11) SC/ST/OBC-A/B/PH/EWS Certificate, if necessary
12) Aadhar Card/Driving License/Voter ID/Pan Card
13) Fees deposit receipt
14) Original Bond with Notary
15) Last Pay Slip (In Service)
16) Release Order, if applicable
NB:- Candidates are hereby directed to keep photocopies of the
original documents which will be kept under the custody of
Principal, B S Medical College, Bankura.
-By order
Government of West Bengal
Office of the Principal
B.S. Medical College, Bankura.
AIQ/STATE
P.G. COURSE
ADMISSION
SLIP
Name of the Candidate:- Dr…………………………………………………………………
Son/Daughter of ………………………………………………………………………………
AIQ Rank………………………………………………. State Rank…………………………
UR/SC/ST/OBC-A/B/ EWS………................................... Subject……………………………
Neet Roll No ……………………………………. Open/Service……………………………
Academic Session 2024-2025. He/She has paid the requisite fees with regard to his/her
admission to the said Course like Admission fees, Caution Money & Tution fees for the
period of six months.
He/She has also deposited his/her following Certificate in original to this office.
1) Final Prof. M.B.B.S. Mark Sheet (Pt-II)
2) M.B.B.S. Degree Certificate
3) Registration Certificate (Permanent)
4) Internship Completion Certificate.
Principal
B.S. Medical College, Bankura.
