Nitte University

INSTRUCTIONS FOR FILLING THE APPLICATION FORM
  • You should ensure that you have filled in all the required information
  • Please ensure that you have submitted the following documents along with the form.
      Attested photocopies of
    • NEET Score card
    • MBBS marks card for all 4 years / degree certificate / internship completion certificate / MCI registration certificate.
    • 10th standard pass certificate for proof of date of birth.
    • Registration fee of Rs 3000/- by DD favoring Nitte University payable at Mangalore.
    • Proof of NRI status (Passport copy of parent, employment certificate, sponsorship letter).
    • Aadhar Card copy of the student.
  • The application form with all enclosures should be forwarded to:

    The Dy.Director (Admin),
    Nitte University,
    University Enclave,
    Medical Sciences Complex
    Deralakatte, Mangalore -575018
    Karnataka State, INDIA

    Tel:+91-824- 2204310 / 2204342 / 2204304

  • For more information visit our website www.kshema.nitte.edu.in or send a mail to info@nitte.edu.in

Application for
MD/MS Program

Year 2017-18
kshema
K S HEGDE MEDICAL ACADEMY
(A constituent unit of Nitte University)

Please mention your first three preferences
SPECIALITY:
First Preference Secnond Preference Third Preference

Please complete all sections of the form. Read the instructions before completing the form
*NEET PG Testing ID *PGET No
*KEA Common Merit *NEET Score
*All India NEET-PG 2017 Rank *Quota Type
Category: OPN (Pvt) GM (Pvt) Govt. Seat NRI Management

A. PERSONAL DATA
*Name Please upload your photograph
Gender Male   Female   Transgender
*Date of Birth (dd/mm/yyyy)
Nationality Mother Tongue
Country of Permanent Residence State of Domicile
Do you belong to SC   ST   OBC   Category1 Any other caste (specify)
Blood group
Father's Name Occupation
Annual income
Mother's Name Occupation
Annual income

B. CONTACT DEATILS
Current address for correspondence click here
to copy the address
Permanent Address
Pin code Pin code
Country Country
Tel No.(with code) Tel No.(with code)
Father's Mobile Number Mother's Mobile Number
*Student's Mobile Number Local Guardian's Mobile Number
Father's/ Mother's E-Mail ID *Student's E-Mail ID
PAN Number( Father ) PAN Number( Mother )
Aadhaar Card Number of the student
Place of residenceUrban   Rural
Hostel RequiredYes   No

C. ACADEMIC QUALIFICATION
Exam Passed College University Year of Passing Marks
MaximunObtained
Class
I MBBS
II MBBS
III MBBS
IV MBBS
Total Marks
Aggregate %
D. Practical training undergone other than required for MBBS
E. MCI Registration number and date
F. References 1.
2.

G. DECLARATION BY THE STUDENT

I have carefully read the details regarding admission to the MD/MS course. I declare that the information provided by me in this application is true and correct to the best of my knowledge. Should it be found that the information furnished is untrue in material particulars, I know that I am liable for criminal prosecution and will forego the allotted seat. In all matters regarding my admission to the course, the decision of the College is final and binding. I am also aware that the college will not refund the fees either in full or in part, under any circumstance. If I intend to discontinue the course at any time after joining, I hereby undertake to pay the college fees and dues as applicable for the remaining years of the course. I agree to abide by the rules and regulations of the College that may be framed from time to time. I am aware that any dispute arising out of the admission to the course will be subject to the jurisdiction of the courts of the city of Mangalore or the Honorable High Court of Karnataka.


Place Agree to the condition
Date22-07-2017

H. DECLARATION BY PARENT OR GUARDIAN
(Declaration to be signed by the guardian, only if both parents of the applicant are not alive)

I,* hereby affirm that the information provided and enclosures submitted thereto in this application of my son/ daughter/ward * for admission to MD/MS course is true and correct to the best of my knowledge. Should it be found that the information furnished is untrue in material particulars, I know that I am liable for criminal prosecution and he/she will forego the allotted seat. I am aware that in all matters regarding his/her admission to the course, the decision of the College is final and binding. If my ward decides to discontinue the course, at any time after joining, I hereby undertake to pay the college fees and dues for the balance duration of the course. I am also aware that the College will not refund the fee either in full or in part, under any circumstance. I am aware that any dispute arising out of the admission to the course will be subject to the jurisdiction of the courts of the city of Mangalore or the Honorable High Court of Karnataka.


Place Agree to the condition
Date22-07-2017

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