CHATRAPATI SHAHU JI MAHARAJ UNIVERSITY, KANPUR - 208 024

 

APPLICATION FOR ADMISSION TO THE D.O.M.S. COURSE

at

 

LAST DATE FOR SUBMISSION OF COMPLETED APPLICATION 

FORM

 

REGIONAL INSTITUTE OF OPHTHALMOLOGY 

EYE HOSPITAL, SITAPUR - 261 001, INDIA

 

  

 

To,  
 

THE DIRECTOR,

REGIONAL INSTITUTE OF OPHTHALMOLOGY

SITAPUR EYE HOSPITAL,

SITAPUR - 261 001

 

Sir,  
 

I hereby apply for admission to the 2 yrs. ensuring course of Diploma in Ophthalmic Medicine & Surgery (D.O.M.S.)

The application fee of Rs. 1000/- is enclosed herewith vide bank demand draft No...............................dated ................................... issued by Nationalised Bank (Name of Bank) ................................................. in the name of Finance Officer, Chhatrapati Shahuji Maharaj University, Kanpur, payable at Kanpur.
   

Yours Faithfully

     
Dated: ....................  

(Signature in full)

PARTICULARS TO BE FILLED IN BY THE CANDIDATE'S OWN  HANDWRITING :

(1) (a) Full name (in Hindi) ___________________________________________________________
1. (b)

Full name

(in English Block Letters)

 ___________________________________________________________
2. Complete address with telephone numbers & Fax/E-mail
(a) For correspondence regarding admission ___________________________________________________________
(b) Permanent Address ___________________________________________________________
3. Father's/Husband's name and complete address ___________________________________________________________
4. Date of Birth (christ. era) ___________________________________________________________
5. Qualifications ___________________________________________________________
6. Religion & Caste ___________________________________________________________
7.

Whether Schedule caste/Tribe/

Backward class, if so, details

 ___________________________________________________________
8. Martial Status ___________________________________________________________

 

(Signature of the Candidates)

9. Domicile/State of residence __________________________________________________________
10. Last attended University __________________________________________________________
11. Name of Medical College from __________________________________________________________
where graduated __________________________________________________________
12. Details of compulsory From____________________________ to _______________________
internship Institution___________________________________________________
13. Details of Registration as (a) No.____________________________________________________
(b) Name of council___________________________________________
14. Experience & engagements after M.B.B.S. (Please write in details) __________________________________________________________
__________________________________________________________
15. Details of M.B.B.S. Exam. Marks & Extra attempts (if any)
Sl. No. Subject Max. Marks Marks Obtained % percent
1 Anatomy      
2 Physiology      
3 Biochemistry      
4 Pharmacology      
5 Path & Bact.      
6 Forensic Med.      
7 S.P.M.      
8 Medicine      
9 Surgery      
10 Obst. & Gyn.      
11 ENT & Eye      
12        
 

TOTAL :

      

DECLARATION:

  1. I hereby declare that information given in this application form is absolutely correct to the best of my Knowledge & Belief.
  2. I have read the detailed rules, relevent ordinances, statutes etc. & undertake to abide by them and, I will not claim any benefit arising out of some error of mistake on the part of the University/Institute.
  3. I am not undergoing any other courses & will not be appearing for any other Exam. during my 2 yrs. D.O.M.S. course except at Sitapur.
  4. I have neither been debarred from admission to post graduate Medical Diploma/Degree Course nor from appearing at any examination by any University on account of use of unfair means or any other reason.
  5. I will have no objection & hereby release from liability all the representatives of Institute/University, for their act, in good faith & without malica in connection with evaluating my credentials and qualification my professional competence, character & other qualification for clinical purpose and hereby consent to the release of such information.

                                                                                                                                         (Signature of Candidate in full)

Encl.: