Government of Jammu & Kashmir
Sher-i-Kashmir Institute of Medical Sciences
(Deemed University) Srinagar-190011

APPLICATION FORM FOR ADMISSION TO D.M/M.Ch COURSES

For office use only
Application No.______
Roll No. ___________
Session ____________        Space for the latest photograph of the candidate

Name of the discipline in which admission sought:__________________________
CD-183 Bank Receipt No. of fee paid _____________________ date of submission__________
(To be filled in by the candidate in BLOCK LETTERS)

01.    Name:____________________________________________________________________
02.    Fathers/Husbands/Guardians Name:___________________________________________
03.    Permanent Home address:_____________________________________________________
__________________________________________________ Pin code __________________
04.    Address for Correspondence _________________________________________________
__________________________________________________ Pin code __________________
05.    D.O.B:_______________________
06.    Gender:         Male(            ) Female(          )Martial Status: Married(           ) Unmarried (    )
07.    Nationality: _________________________ State of Domicile:_______________________
08.    Whether presently:     employed (PSC) __________         Unemployed (Non PSC) _______
Tenure appointment __________________
09.    Present place of posting _________________________ Date of appointment __________
10.    Contact No: Phone: ______________________________ Cell : ______________________
11.    Academic Qualification
Undergraduation
SNo    course    Name of University/college    Year of passing    No. of Attempts    Total & %age of marks in MBBS aggregate


(Certificates to be enclosed)
Postgraduation
SNo    course    Subject    Name of University    Year of passing    No. of Attempts



Dated                                     Signature of the candidate














12.    Declaration by the candidate:
I hereby declare that:
(a)    The statements made, informatics, furnished in this application form and the enclosure submitted by me are true and correct;
b)    I have not concealed any information and in the event of any of the particulars/information given hereinabove is found incorrect or false, my candidature for the entrance examination may be cancelled.
c)    In the event any mis-statement/discrepancy is found at the time of admission or at later stage, my admission/selection may be cancelled.



Signature of the candidate


13.        Declaration by the Father/Husband/Guardian;
I have fully read the information furnished by my son/daughter/wife and affirm that it     is correct and true to the best of my knowledge. In case it is proved that the     information furnished above is found incorrect any time during the training period,     SKIMS (Deemed University) shall be at liberty to initiate legal proceedings against     him/her.



Sig. of the candidate’s
Father/Husband/Guardian

14.    Forwarding Note: (to be signed by the Employer, if employed)
I hereby certify that Dr. _____________________________ is presently working in the ________________________ department for the past _____________ years on regular/temporary basis. The application is being made with my permission and that he/she will be relieved to join DM/M.Ch course at SKIMS within fifteen days after the issue of his/her selection letter in his/her favour.


Sig. of the employer with
Seal and complete address

Enclosures to be submitted along with this form: (All attested copies of the following certificates)
Tick mark in the box for the enclosed certificate.

1.    (         ) MD/MS/Degree certificates        2.    (          ) MBBS Degree Certificate
3.    (         ) All MBBS Marks Certificates        4.    (          ) Internship completion Certificate
5.    (         ) Date of Birth Certificate            6.    (          ) State Subject Certificate
7.    (         ) Permanent Registration Certificate    8.    (          ) Self Addressed envelop with
Postal stamp affixed thereon.