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, 4, 5, 10(a) and 11.

2. Full Name of applicant (In CAPITAL Letters and as per matriculation certificate) Please don't write Dr./Mr./Mrs./Ms. before names.

3. a) Father's/Husband's Name (In CAPITAL Letters)

b) Mother's Name (In CAPITAL Letters)

4. Gender

Male Female

5. Nationality

Indian Others Date

6. Date of Birth

Month Year

7. Details of BDS examination passed

(a) Month & Year of Admission

MONTH YEAR

(b) Month & Year of passsing the examination

MONTH YEAR

c ) Total Marks in 1st+2nd+3rd+4thMaximum Marks Marks obtainod Percentage

Th H T O Th H T O

9 (a). Date of starting Internship

Date Month Year Date Month Year

(b) Date / Expected date of completion of Internship (c) No. of days

10. from which BDS

Name of College/University passed 13 (a). PHOTOGRAPH

POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH

(To be assigned by office)

Challan/Journal/INB Reference No .........................................................................................................................in favour of Director, PGI , Chandigarh

Paste Passport Size

coloured Photographwith

Name and Date

DETAIL OF FEE:

1. Category

OBC Schedule Tribe

1

Any deviation or discrepancy between actual appearance at the time of examination and facial appearance in the photograph pasted on the application will make the candidate liable for rejection.

(Note : The Change of category at any stage will not be permitted, tick only in one box)

(a) Whether recognized by Dental Council of India ?

11. Have you already done or doing House Job?

YES NO

13 (b). SIGNATURE OF THE CANDIDATE(Use Black Ball Pen Only)

................................................................................................................................................................................

8. Medical Registration Detail:

a) Permanent/Provisional b) Statec) Date of Registration

D YD M M Y YY

For Office use only

APPLICATION/REF. NO ...............................................................................................................

APPLICATION FOR THE ADMISSION IN HOUSE JOB (OHS) COURSE FOR JANUARY-2015 SESSION

.

3rd Gender

YES NO

12. MOBILE NO.

14. Address :

A) Permanent Home Address :

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

Contact No. of home with STD Code__________________________

Mobile No.: _____________________________________________

E-mail: _________________________________________________

B) Correspondance Address :

_______________________________________________________

_______________________________________________________

_______________________________________________________

_______________________________________________________

Contact No. with STD Code_________________________________

Mobile No.: _____________________________________________

E-mail: _________________________________________________

17. State/Union Territory to which you belong : ________________________________________________________________

18. Are you employed if yes, give the following details : a) Date of Joining as regular service : ________________________________________________________________

b) Nature of job (Permanent/Contractual/Adhoc) : ________________________________________________________________

c) Name of the Institution/Hospital Govt./ Semi Govt./ Pvt. : ________________________________________________________________

d) Designation ________________________________________________________________:

: e) Pay Scale ________________________________________________________________

f) Name of employer ________________________________________________________________:

19. 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 '5 : ________________________________________________________________

20. Have you any contact person/guardian in Chandigarh. If so, mention his/her address Telephone No., If any. : ________________________________________________________________

15. Married or Unmarried :________________________________________________________________ (If married, wife/husband name and occupation)

16. Nationality : ________________________________________________________________

*There is no need to fill the above certificate in case the Internship Certificate has already been issued by the Institute/Hospital/College (Attach attested copy)

2

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 fromwhere the candidate or is undergoing internship.

3DECLARATION BY CANDIDATE

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 as

such 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

Address ____________________________________

___________________________________________ Signature

Relationship to the applicant)

ENDORSEMENT BY THE EMPLOYER, IF THE APPLICANT IS IN SERVICE

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.

No........................... Date ......................

Forwarded to the REGISTRAR, Postgraduate Institute of Medical Education and Research, Chandigarh forconsideration. The undersigned has no objection to the applicant of Dr. ______________________being considered bythe Institute for the course applied for by him/her and if selected, he/she will be relieved within, the prescribed timelimit. 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

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. The OBC Certificate submitted by the candidate shall be issued by the Competent Authority with in one year of the last date of submission of application.

I......................................................................................................son/daughter of Shri................................................................................................................................................resident of village/town/city...............................................................................district..........................................................state.............................................................................................................................(certificate enclosed) hereby declare that I belong to the ..............................................................................................communitywhich is recognized as a backward class by the Govt. of India for the purpose of reservation in services as per orderscontained in Department of Personnel and Training Office Memorandum No. 36012/22/93-Esstt(SCT)dated 8-9-1993. It isalso 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

DECLARATION TO BE SIGNED BY OBC CANDIDATES ONLY

Place ..............................Date ...............................

(Signature of applicant)(in running handwriting)

1.

4Documents Enclosure No.

1. Self attested copy of Matriculation / Higher Secondary CertificateShowing Date of Birth

_________________________

2. Self attested copy of BDS Passing Certificate _________________________

4. Internship completion certificate _________________________

_________________________5. Self attested copy of Certificate of permanent Registration with Central / State Dental Registration Council

_________________________6. Self attested copies of following Certificates

(See performas in Prospectus) whatever applicablei) Caste Certificate in Prescribed Form SC/ST (Annexure- '2' (in Hindi or English Version only)ii) Fresh (should be issued within one year) OBC Certificate (Annexure -'3')

APPLICATION MUST BE TAGGED PROPERLY & ALL THE ENCLOSURES MUST ACCOMPANY THE APPLICATION IN SEQUENCE AS PER THE ENCLOSURE LIST GIVEN BELOW

8. Three self addressed envelopes of size 10x23 cms. Rs. 10/- Postage stampon each envelope for use by this office for sending interview letter etc. _________________________

Date _______________________________

Place _____________________________

No. of Enclosures : ___________________ Signature of the Candidate

IMPORTANT NOTEIn case any candidate is found to have supplied false information of to have concealed or withheld some information in his/her application form, He/she shall be debarred from admission.

certificate etc. or is found

Any other action that may be considered appropriate by the Director of be taken against him/her which may include criminal prosecution.

the Institute may also

Attach Challan Form in original (PGI Copy)9.

3. Self attested copies of detailed mark sheets of BDS (all semesters) _________________________

_________________________

Please stapledthree extra

Passport sizecoloured

photographs here

7. Sponsorship Certificate in original (Annexure-5) if applicable _________________________

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