Form Med0809

Telephone: 080 26995000 - 20 / 26995015 Fax: 080 26564830 / 26562121 Grams: NIMHANS

Application for MEDICAL Course

PLEASE RETAIN THIS SHEET WITH YOU

NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES (DEEMED UNIVERSITY) Post Bag No.2900, Bangalore - 560 029 INSTRUCTIONS TO THE APPLICANTS FOR POST GRADUATE COURSES (Please adhere to the following instructions strictly) 1. Fill in the application in BLOCK LETTERS (Insert one letter in each block). 2. Fill in √ where applicable, eg. Mr.X. Male

Female

3. Copies of all certificates supporting the claims made in the application must be enclosed. 4. Affix one recent passport size photograph to the application form on the front page. 5. Employees of the State Government or of any public undertaking should send the application through their employer. However, an advance copy of the application (complete in all respects) can be sent. In case the application is not received through the employer before the Entrance Test, a 'No Objection Certificate' issued by the employer should be produced at the time of Entrance test, without which the candidate will not be permitted to appear for the Entrance test. 6. Applicants from Foreign Universities/Countries must submit their applications through the Diplomatic Channel (through the Ministry of External Affairs). 7. Candidates who are doing their Internship/Compulsory rotatory job may also apply. But, such candidates will be eligible to appear for the Entrance test only if they can produce the proof of completing their Internship on on before 2nd May 2008 on the day of Entrance Test. Otherwise, the application will be rejected 8. The last date for receipt of application is 5th November 2007

9. APPLICATIONS RECEIVED AFTER THE DUE DATE WILL NOT BE CONSIDERED.

10. INCOMPLETE APPLICATIONS WILL BE REJECTED.

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NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES (DEEMED UNIVERSITY), BANGALORE - 560 029 APPLICATION FOR MEDICAL COURSES Application No.

Roll No. (For Office use only)

Affix recent passport size photograph duly signed by the candidate across the photograph

(For Office use only)

Application for admission to (√ in appropriate boxes only) DM in Neuroradiology DM in Neurology M.Ch. in Neurosurgery MD in Psychiatry Diploma in Psychiatry Post Doctoral Fellowship in Neuroanaesthesia Post Doctoral Fellowship in Neuropathology Ph.D. in (Subject) Name of the Candidate

(Signature of the Candidate)

Postal Address P

I

N

P

I

N

Phone (Resi) (Off) (Mobile) Fax/Email ID Permanent Address

Father/Guardian/ Husband's Name Occupation

Annual Income Rs.

Mother's Name Occupation

Annual Income Rs. D D M M Y Y Y

Sex

Male

Female

Date of Birth

Age Years

Caste* Category

SC

ST

OBC Others

Physically Handicapped

Yes

Nationality

Indian

Others

If yes, enclose certificate#

No

State in which you are domiciled** D D M M Y Y Y Qualification*** Have you passed the qualifying exam

Yes

No

Date of Completion of Internship If no, the date of results

Are you being officially Sponsored* by State/Central/PSU Details of payments

Yes

No

D D M M Y Y Y

If yes, enclose details

a) Application fee DD No.,Date _________________ Amount _________ Bank _______ b) Registration fee DD No.,Date _________________ Amount _________ Bank _______

*Relevant Certificates as applicable to be enclosed. **Domicile Certificate to be enclosed if applying for # Refer Prospectus for details Diploma in Psychiatry course. ***Details to be provided in the following pages

Sl. No.

Examination Passed

Name of College and Place

University/ Institution

Date of Entry

DOWNLOADED Date of No. of Aggregate Marks Subjects Leaving attempts obtained in Final Year Studied

1 I MBBS 2 II MBBS 3 Final MBBS Part I Part II 4 M.Sc./MA

5 Postgraduate Diploma Diploma Name

6 Postgraduate Degree Subject (Enclose Copies of Certificates to confirm above statements without which, this would not be considered) Whether the college in which you have studied/passed is recognized by Medical Council of India? Medical Council Registration No, State and year of Registration Fellowship from UGC/ICMR/DBT/CSIR

YES/NO

YES/NO

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Declaration by the Applicant 1. I agree to undergo the course on a full time basis and shall not engage myself in any kind of private practice during the period of the course. I will not pursue any part time course elsewhere unless permitted by the Institute. 2. I agree that during my stay at the Institute, I shall not draw my pay/allowances or fellowships from any other source if I am employed as a resident. 3. I declare that I shall abide by the Rules and Regulations of the Institute and those that are framed from time to time. 4. I hereby declare that the information given in this application is true and correct to the best of my knowledge and belief. In case any information given in this application proves to be false or incorrect, I shall be responsible for the consequences. 5. I agree that I will not indulge in ragging and am aware that Ragging is banned in this Institution, if at any point of time, I am found indulging in Ragging, appropriate punishment may be initiated against me including explusion from the Institute.

Place: Date:

(Signature of the Applicant) Name in Block Letters:

Declaration by the Parent/Spouse/Guardian of the Applicant I hereby declare that I am responsible for the timely payment of all the dues to the National Institute of Mental Health and Neuro Sciences, Bangalore in respect of my son/daughter/ward/spouse (Name)_________________________________________________ during the period of his/her study at the Institute and therefore until the accounts are cleared. I am also aware that Ragging is banned in this Institution. Appropriate punishment may be initiated against my son/daughter/ward/spouse if found indulging in Ragging including expulsion from the Institute.

(Signature of Parent/Spouse/Guardian of the Applicant)

Forwarding note to be signed by the Employer under whom the Applicant is employed I certify that the application is being made with my permission and that there is no objection to release the applicant if selected for the courses, within the prescribed limit of time. I also certify that I shall inform the authorities of the National Institute of Mental Health and Neuro Sciences, Bangalore about the financial terms and remit Salary, Leave Salary, Study Leave Salary, Deputation Allowances etc. to the Institute Account which will be paid to the applicant for the period of this training from the Institute.

Place: Date:

(Signature of the Employer) Office seal and address of Employer

NATIONAL INSTITUTE OF MENTAL HEALTH & NEURO SCIENCES BANGALORE-29 (DEEMED UNIVERSITY) ADMISSION CARD FOR WRITTEN TEST ENTER PARTICULARS IN CAPITAL LETTERS ONLY COURSE APPLIED FOR: DM IN NEURORADIOLOGY, DM IN NEUROLOGY, M.Ch. IN NEUROSURGERY, MD IN PSYCHIATRY, DIPLOMA IN PSYCHIATRY, PDF IN NEUROANAESTHESIA, PDF IN NEUROPATHOLOGY, Ph.D. in_________ (STRIKE OFF THE COURSE NOT APPLICABLE) 1.FullName________________________________________________________________________ 2. Sex : M /F Affix one latest/ Day Month Year recent photograph 3. Date of Birth: duly signed by the 4. You belong to SC / ST / OBC / Others candidate and attested by a Gazetted Officer

(For Office use only) Application No………………………………………… .Roll No……………………………………

Signature of the candidate

(At the examination Center) Signature of Candidate

Signature of Supervisor