FORM – DDT MOTHER THERESA POST GRADUATE & RESEARCH INSTITUTE OF HEALTH SCIENCES (MTPG & RIHS) (A Government of Puducherry Institution) Indira Nagar, Gorimedu, Puducherry-605 006 Phone: 0413-2271200, 2275566, 2273008 Fax : 0413-2277594 Website: http://mtihs.puducherry.gov.in Email: [email protected] APPLICATION FOR ADMISSION TO THE DIPLOMA IN DIALYSIS TECHNOLOGY (DDT) COURSE FOR 2014-15 (FOR OFFICE USE ONLY) Registration No. : Merit Marks : Overall percentage of marks obtained : Category of the Applicant : Category under which selected : Wait List No. : Merit Rank MTIET(Dip)-14 : marks Date: Note: (i) (ii) (iii) (iv) (v) (vi) : DEAN Last date for the receipt of duly filled-in application is 25-06-2014 (Wednesday) by 05:00 pm. Incomplete and late application will not be considered. Please read carefully the Information Brochure before filling up the application. All entries must be in the applicant’s own handwriting legibly in Capital Letters only Do not overwrite the entries. All columns must be filled in. (Write “NA” wherever not applicable) Affix recent passport size photograph attested by a Gazetted Officer PART – I 1. Name of the Candidate : 2. 3. Father’s / Guardian’s Name : (a) Date of Birth : (b) Age as on 31.12.2014 : (c) Nationality : Day Month Year Years Months Days 96 -24. Gender (Please tick []) : Male 5. Marital Status (Please tick []) : Married (a) Address to which communications are to be sent : 6. Female Unmarried PIN (b) Permanent Address : PIN 7. (a) Contact Telephone No. : (b) Mobile Number (Essential) : 8. 9. 10. 11. (c) E-Mail ID (Essential) : (a) Religion : (b) Community : (c) Caste : Please tick [] the category : under which seeking admission If belongs to OBC / SC, whether Origin or Migrant (Please tick []) Special Allocation (Please tick []) if applicable 12. Domicile Status (Resident of) (Please tick []) 13. Region against which the candidate claims reservation (Please tick []) 14. GEN OBC BCM MBC EBC BT SC ST : ORIGIN FF MIGRANT PC EX-SM SP : : Pudcherry U.T Puducherry Other States / U.T Karaikal Mahe Yanam : Details of Qualifying Examination - (Under Graduate) (i) Name of Degree Examination (ii) Whether passed? (Please tick []) : : (iii) Name of the University : (iv) Name of the College & Address : Yes No …………………………………………………………………………………………………… …………………………………………………………………………………………………… …………………………………………………………………………………………………… 97 -3- 15. Marks obtained in Qualifying Examination (Degree or its equivalent): Details of Marks Course Name of the College Year of Passing University Division Sem./ Year Marks secured Max. Marks I II III IV V VI VII VIII TOTAL Marks 16. 17. (a) No. and Date of the D.D towards : application fee (b) Amount : (c) Name of the Bank : Any other relevant information : Dt. Rs. …………………………………………………………………………………. DECLARAT ION BY THE APPLICANT I hereby solemnly affirm that the statements made and information furnished in the application and all the enclosures submitted by me are true and no relevant fact is suppressed by me. I have read and understood the Information Brochure carefully. I shall abide by the rules and regulations of the Mother Theresa Post Graduate and Research Institute of Health Sciences, Puducherry. Place: Date: Signature of Applicant DECLARAT ION OF PARENT / GUARDIAN O F THE APPLICANT I hereby declare that the statements made and information furnished in the application and all the enclosures thereto are true and no relevant fact is suppressed. I have read and understood the Information Brochure carefully. I also declare that I hold myself responsible for all payments due to the Institute in respect of my son/daughter/ward Thiru / Tmt. / Kumari.............................................................................................................. Place: Date: Mobile No. : Signature of Parent/Guardian (Essential) 98 DDT -4- PART – II CHECK LIST (To be filled by applicant) A. Attach the following certificates / documents with the application. (Tick [] the relevant boxes) 1. Birth Certificate or any Certificate for proof of date of birth : 2. Puducherry UT Residence / Nativity Certificate – Recently issued / Revalidated : 3. Nationality Certificate : 4. Caste / Community Certificate- Recently issued/ Re-validated in 2014 : 5. S.S.L.C. / Matriculation Mark Sheet : 6. Higher Secondary (+2) Mark Sheet : 7. Degree Certificate/ Provisional Certificate : 8. Statements of marks of qualifying examinations (All Semesters/years) : 9. Transfer Certificate & Conduct Certificate issued by the Head of Institution last studied : 10. Regional Claim Certificate in the prescribed format : 11. Certificate issued by Competent Authority for claiming Special Category Reservation (Applicable to Freedom Fighter, Physically Challenged, Ex-Servicemen and SP categories) : : 12. Medical Fitness Certificate issued by Competent Authority 13. Crossed Demand Draft for Rs.500/- (Rs.250/- for SC) towards Application Fee : : 14. Any other relevant certificates B. Verify the following – (i) Passport size photograph affixed and duly attested by a Gazetted Officer : (ii) Whether details of marks obtained in Qualifying Examinations (Degree or equivalent), is entered : (iii) Furnished declaration of Applicant duly signed : (iv) Furnished Declaration of Parent / Guardian duly signed : (v) Crossed Demand Draft enclosed : (vi) Whether name of candidate & name(s) of Course written on backside of D.D : Signature of Applicant: ………………………………………………….. FOR OFFICE USE ONLY The above Column A and B verified and found correct. Signature of the Clerk / in-charge : ……………………………………. Name & Designation Date: 99 : ……………………………………. DDT MOTHER THERESA POST GRADUATE & RESEARCH INSTITUTE OF HEALTH SCIENCES (A Government of Puducherry Institution) Indira Nagar, Gorimedu, Puducherry-605 006 Phone: 0413-2271200, 2275566, 2273008 Fax : 0413-2277594 Website: http://mtihs.puducherry.gov.in Email: [email protected] HALL TICKET – MTIET (Dip)– 14 Affix recent passport size photograph attested by a Gazetted Officer ENTRANCE TEST – 2014-15 For Admission to Diploma in Dialysis Technology (DDT) Course Registration No. Name of the Candidate Name of the Centre Mother Theresa Post Graduate & Research Institute of Health Sciences, Indira Nagar, Gorimedu, Puducherry-605 006 Date and Time of Examination 29-06-2014 (Sunday) at 11.00 a.m. Signature of the Candidate Note : If the Candidate does not fulfill the eligibility criteria and does not produce the requisite certificates at the time of counselling, he/she shall forfeit the right of selection without any further correspondence though he/she might have appeared for the Entrance Examination. (DR. R. MURALI) DEAN 100
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