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GOVT.

DENTAL COLLEGE AND HOSPITAL, JAMNAGAR


GUJARAT (INDIA)
Phone: (O) 02882550369
(PBX) 0288 2ss03s2
Fax : 0288 2550369
Navagam Ghed
Jamnagar.361 008
Dtt'l'A
Name of the student
Native State
Adm. Memo no. & Date
Caste &
Catesorv
(OP/SC/
ST/SEBC)
Total Marks in Sci. sub. as per
HSC Marksheet
Name & Address of the school
(last
studied)
Birlh Date & Place (as per
school leavins eerti.)
Name of parents ( Father and
Mother)
Residential Address with
Phone no.
Name & Add. Of local
guardian (if any)
Date of Adm in coilese
Hostel Facilitv required. Yes / No
Date of Adm. in hostel
Hobbies
No student is allowed to go to picnic personally or collectively. A prior written
permission of the Dean is a must after which the warden will allow such activities.
In daily routine, hostel warden's instructions should be scrupulously followed.
Any indiscipline or violation of rules can result in termination of hostel admission.
I agree to abide by the aforesaid rules.
STUDENT PERSONAL
Affix your recent
passport size
photo here
Signature of Parent/ Guardian:
Dean,
Govt.Dental College & Hospital
Jamnagar
Student's Signature:
Date:
Place: Jamnagar
D:WISHAL KHETIYA - l\Admission form\Student personal details form.doc
GOVT. DENTAL COLLEGE AND HOSPITAL, JAMNAGAR
GUJARAT (rNDtA)
Phone:
{O}
02882550369
(PBX) 0288 zss03s2
Fax : 0288 2550359
Navagam Ghed
Jamnagar. 361008
(FOR OFFTCE USE ONLY)
To,
Accounts Branch,
Gov. Dental College & Hospital,
Jamnagar
Please accept ttre tottowing fees from Mr. /Miss.
for admission to first B.D.s. course in this college as per admission order
no... .. . ... dated.
Caution money deposit
(Rs. 1000.00)
1000.00
Library fee
(Rs 10.00)
10.00
Hostelfees
(Rs. 1200.00 per year)
1200.00
Tution fees
(Rs. 4000.00- for AIPMT students only)
Others
Total fees
Dean,
Govt. Dental College & Hospital,
Jamnagar.
To,
Std. section
Received fees as stated above via receipt no. ... ..... dated
Sign:
Acc. Branch, G. D. C.H., Jamnagar
D:\VISHAL KHETIYA - 1\Admission form\.Fees order.doc
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Government Dental College & Hospital, Jamnagar.
'
Form For Application For The Girls And Boys Dental Hostel
1. Name:-
(Surname) (Name) (Father' name)
2. Present Address :-
3. Permanent Address :-
4. Relationship With Guardian (lf Any)
5. Guardian'name
& Address :-
6. The college term for which application for :-
7. Telephon e
/
Mo. No. Student,Mother, Father, Brother,sister
Signature of applicant :-
Note :-The applicant should state clearly if the guardian is resident in Jamnagar.
The collage term :-
L.
2.
3.
4.
WARDEN
Girls and Boys Dental Hostel
Government Dental College & Hospital,
Jamnagar.
Personal Detail's of student who got admission in B'D.S' Course during the
Year 200 - 200 .During the term commencing from
""""""""j""""'
. PHOTO
l-. Name :-
2. Date Of Birth :-
3. Father Name & Address :-
4. Father'sOccu
Pation
:-
& Address, Contact No.
5. Local Address Of Guardian
(lfany)
6. Total Marks Obtained in Science subject :-
7. Date of Admission in'college :-
8. Date of Admission in Hostel :-
9. Reserved in ( if anY
)
( o.M./s.c./s.r./sEBS/CBSEc)
Date :-
Place :-
Signature of Student
No student is allowed to
go to picnic in personal or collectively, first the written
permission
of Dean should be obtained and then the warden will allow prior permission
ls a must.
ln daily routine, the hostel superintendent's
instruction should be scrupulously
Followed. And indiscipline behaviour or violation of hostel rules will be reselted in
Termination of hostel admission.
I abide by the dforesaid rules and regulation of hostel
Signature of parents :-
Date :-
Signature of Student :.
Date :-
Ssursstrs
University
Re-Accredited
Grade '8, by NAAC (CGpA
2.93)
Enrollrnent Forrn
Frovisional Eligibi!ity Certif!cate Details
Passine Month:
Total Marks;
Obtained t\/larks:
School Narne :
Scho,:l Completion
year:
School Enroll Date:
Othen Courses done after HSC:
Higher Secondary
Subject Details
Attach Your
Fassport Size
Photograph
with Stapler or
a pin only
Board Name
Provisiona I Eligibility Certi.No:
Elieibility Certi.Date:
Transfer Certi.No:
Transfer Certi.Date :
General Details
FATHER'S/H
USBAND NAM E:
i_y_.9c/qv:E9_cl9!9!
Date of Birth:
Nationality
Residential
address:
Pin code
Mobile/Fhone No.
District
ls Physically
Handicap:
yes/
No
Details of Frrevious Exam
HSC Seat No.
Passing Year:
Atte rn
pt:
Percentage
School Completion month
School Leave Date:
0btained Manks
c:\Documents
and settings\abc\Desktop\saurastra
University Enroll New.docx
Page I of I
GAZETTE
OF INDIA.
PART III- SEE. 4. EXTRAORDINARY.
ANNEXURE:I
PART- I
UN DERTAKING
BY THE CANDIDATE/STUDENT
L' l' ------------
- s/o.
D/o. of Mr./Mrs./Ms.
-----_______
__have
;il:iti:t
read and fullv understood
the law prohibiting
ragging
and the directions
of the
supreme
court and the centrar/state
government
in this regard.
2 I have received
a copy of the DCI iegulations
on the curbing
the menace
of ragging
in Dental
colleges,
2009 and have carefully gon"
tf..,rorgfit.
3 I hereby
undertake
that
'
I will not indulge
in any behavior
or act that may come under
the definition
of
ragging.
. I will not partipipate
in or abet or propagat
ragging
in any form.
'
I will not hurt anyone physically
or psychologiiitry
o. cause any other harm.
,1.,.'
nuruoy
agree that if found guirty
of any ,rp.J
oi ir*s'nr,
r may be punished
as per
Provisions
of the DCI regulations
mentioned
above
and
/or as perthe
law in force.
irrr,r",ljjleby
affirm that r have not been expeted
or debarred
from admission
bv any
Signed
this ------
-day
of*_ ________month
of__________________year
2.
3.
Signature
of student
ANNEXURE
_I
PART-
II
UNDERTAKING
BY THE PARENT
/
GUARDIAN
l,-------------
_F/O.M/o.
G/o_
_________
have
carefully
read and fully understood
the law prohibiting
ragging
,.o,n.ilr..ion,
ot
the hon'ble
supreme
court and the central/state
gouuinr".nt
in this regard
as well
as the DCr regurations
on curbing
the menace
of ragging
in dentar coileges.
2009.
I assure you
that my son/daughterlward
wiil not inl"ure".
in ,ny act of ragging.
I hereby agree that if helshe is found guirty
of any ,rpJ.t
of ragging,
he/she
may be
punished
as per
the provisions
of ttre oct regulationsmentioned
above
and/or
as
per
the law in force.
Signed this
--
day of:--------------month
of______________year
Signature
of
Parent
/
guardian
Name:
Address:
FORM OF CERTIFICATE
MEDICAL CERTIFICATE OF EXAMINATION OF A CANqIDATE FOR ADMISSION TO
MEDICAL & PARAMEDICAL COURSES
I hereby certify that I have examined Shr/ Kum/ Smt..'....""
....., a candidate for admission to Medical/Paramedical Course and cannot discover that
he/she has any disease, constitutional weakness or bodily intirmity except
I do not consider this a disqualification
.for
admission to the Medical/Paramedical course. Hislher age,
according to his/her own statement, is ..............."....years and appearance is
'.....'..'..".
years.
Mark of ldentification:
-
lmpression of Left thumb
('1) Signature
(2) FullName
(3) Qualification
(Minimum M.B.B.S,)
(4) Flegistration No.
Date : / /20
UNDER
TAKITSG
,,
I hereby agree to coniorm to the rules and regulation at present in force or that may hereafter be made for
governance of Medical and
paramedical
courses and I undertake that during such course, I will cio noihing either inside
or outside the college that will interfere with the orderly
governance and discipline. I am also aware that ragging is banned
and if found
guilty, I shall be liable for cancellation of admission and punishment as per rules";
Date:
Place:
Signatur,e of the Candidaie
Signature ol the ParenV Guardian

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