Beruflich Dokumente
Kultur Dokumente
First Name 1. Name of the candidate (IN BLOCK LETTERS) 2. Fathers Name 3. Mothers Name 4. *Guardians Name 5. Relationship
Middle Name
Last Name
*Any person, other than the parents of the candidate, can become guardian only if the parents are not alive or are insane.
Affix your recent Coloured photograph duly signed by the candidate and attested by a Competent officer as explained in Information Booklet
6. Date of Birth
(DD) (MM) (YYYY)
8. Sex
Male/Female
9. Nationality ......................... 10. Religion............................... 11. State............................ 12. Place of Birth......................................... 13. Rural/Urban .............................................
14. Occupation of Father/Guardian............................... Annual Income Rs. .......................... (Govt./Pvt.) If in Govt. Service mention details of the post.................................................................... 15. (i) Address for Correspondence (ii) Candidates Permanent Address
PIN Telephone No. with STD Code Mobile No. 16. Category (General Boy/SC Boy/ ST Boy/ Scheduled Area Tribal Boy/OBC Boy/ SBC Boy/General Girl/SC Girl/ST Girl/Scheduled Area Tribal Girl/OBC Girl/ /SBC Girl) 17. Additional Category, if any (PH/DP/PM) Telephone No. with STD Code Mobile No.
PIN
(1)
18.
Details of Educational Institutions where the candidate studied during last 10 years.
Years Name of Institution Class in which Studied Name of City/Village and State
2010-2011 2009-2010 2008-2009 2007-2008 2006-2007 2005-2006 2004-2005 2003-2004 2002-2003 2001-2002
2.
3. 4.
5.
6. 7.
(Signature & Seal) Signature & Thumb Impression should be verified and marked in presence of Principal of School/College last attended/ Gazetted Officer/Executive Magistrate. Note : Candidate must sign the form and affix left & right Thumb Impressions failing with the application form will be rejected.
Place : ..........................
(2)
3.
Signature of Father/Mother/Guardian
*If natural father is not alive. #If natural parents are not alive or are declared insane.
of my School/College has passed Exam in all the subjects of Senior Secondary, (10+2) Equivalent examination with particulars given in Academic Record Table as below : Academic Record Table
Roll No. Year of Passing Board Division Physics Chemistry Biology English
Max. Marks Max. Marks Max. Marks Max. Marks Mark Obtained Mark Obtained Mark Obtained Mark O Obtain
ed
CERTIFICATE NO. 3
CERTIFICATE OF ELIGIBILITY
NOTE : Any one out of following eleven Certificates (I-XI) is necessary, failing which the form shall be rejected.
I Certify that Shri/Kumari ................................... Son/Daughter of..................................... has studied for the last three years of the qualifying examination (X-XI & XII) continuously as a regular candidate in recognised Institution in Rajasthan and is an Indian National.
Signature of the Head Master/Principal/ Head of Institution last attended With Official Seal
II
I certify that Shri/Kumari .................................................................. is the natural Son/ Daughter (not adopted) of Shri/Shrimati......................................................... and his/her Father/Mother has been continuously residing in Rajasthan for a period of 10 years and that he/she has studied for at least 5 years in this period in recognised educational institutions in Rajasthan. The details of period of study in recognized educational institutions are given in Proforma on Page 2.
Signature of the District Magistrate/ Addl. District Magistrate/ Sub. Divisional Magistrate Executive Magistrate
IV
I certify that Shri/Smt ........................................................................... Father/Mother of Shri/Kumari............................is serving/retired (i) employee of Government of Rajasthan or (ii) is an Officer of All India Service born on the State Cadre of Rajasthan. He has served for m or e t h a n 3 years with t h e St at e G o v e r n m e n t as............................ for t h e period from.....................to........................... in the Department of............................. (designation). Date................ 2011 Place .............. Signature of the Employer/ Head of the Department Designation and Seal
Certify that Shri/Shrimati ........................................................................ Father/Mother of Shri/Kumari ........................................................... is a serving/retired, permanent employee of Government Undertaking/corporation/Improvement Trust/Municipal Board/Council/ Panchayat Samiti/Co-operative Bodies, duty constituted by the Government of Rajasthan by an Act of Law who has put in atleast three years of service on the last date of submission of application in the year of admission. He/she is in service as...................... in the....................... since ................... (designation)......................................... (Body/Dept.) Date................ 2011 Place .............. Signature of the Employer/ Head of the Department Designation and Seal
VI
Certify that
of Shri/Kumari..................................... Education, Rajasthan and has put submission of application in the as.................................in the
University (Name) ......................................................... in Rajasthan or Board of Secondary in atleast three years service on the last date for year of examination. He/she is in service
.......................................... since ..................... (designation) ......................... (Body/Dept.) Date................ 2011 Place .............. Signature of the Employer/ Head of the Department Designation and Seal
VII
CERTIFICATE UNDER RULES 3 (C) (v) FOR DEFENCE PERSONNEL OF RAJASTHAN ORIGIN
I certify that Shri/Kumari........................................................is a natural Son/Daughter of Shri/Shrimati.............................................. and his/her Father/Mother is serving/retired permanent employee in Indian Defence Service and he/she is of Rajasthan origin and the home town as given by him/her at the time of his/her entry into service is................................. town............................ Dist.......................... State.................................... He/she comes under priority* .................. meant for the Wards of Defence Personnel. (*See Priorities I to IV as mentioned in Information Booklet). Date................ 2011 Place .............. (5) Signature of the Employer (with Official Seal)
VIII
CERTIFICATE REGARDING DEFENCE PERSONNEL NOT OF RAJASTHAN ORIGIN BUT SERVING IN RAJASTHAN
I certify that Shri/Kumari....................................................... is a natural Son/Daughter of Shri/Shrimati .............................and his/her Father/Mother is serving employee of Defence Service of India. He has been in the service for the last..................... years and is working on the post of .......................................... from .................. in this unit and is posted in Rajasthan since......................and is continuing in Rajasthan at present. He/She comes under Priority ....................................... meant for Defence Personnel. Date................ 2011 Place .............. Signature of the Employer (with Official Seal)
IX
CERTIFICATE UNDER RULE 3 (C) (vi) FOR PARA MILITARY PERSONNEL OF RAJASTHAN ORIGIN
I certify that Shri/Kumari .................................................. is a natural Son/Daughter of Shri/Shrimati ............................................. and his/her Father/Mother is serving/retired permanent employee in Para Military Force and he/she is of Rajasthan origin and the home town as given by him/her at the time of his/her entry into service is ............................. town ...................................... Dist................................ state............................ Date................ 2011 Place .............. Signature of the Employer (with Official Seal)
CERTIFICATE REGARDING PARA MILITARY PERSONNEL NOT OF RAJASTHAN ORIGIN BUT SERVING IN RAJASTHAN
I certify that Shri/Kumari....................................................... is a natural Son/Daughter of Shri/Shrimati....................................................................... and his/her Father/Mother is serving employee of Para last......................... years Military Forces. He and is has been in on the service for the post the of working
..................................since..............................in this unit and is posted in Rajasthan from ....................... and is continuing in Rajasthan at present. Date................ 2011 Place .............. Signature of the Employer (with Official Seal)
XI
CERTIFICATE UNDER RULE 3 (C) (vii) FOR SON/DAUGHTER OF A JUDGE OF RAJASTHAN HIGH COURT
I certify that Shri/Kumari........................................................ is a natural Son/Daughter of Shri/Shrimati ............................................................................... A Judge of Rajasthan High Court subject to that he/she submits an undertaking/affidavit stating that such benefit is not being claimed or availed by him/her in any other State. Date................ 2011 Place .............. (6) Signature of the Employer Rajasthan High Court (with Official Seal)
(7)
1. 2. 3. 4. 5.
Marksheet of passing the Secondary School Exam. Marksheet of passing the Senior Secondary School/10+2 or equivalent Exam. (if appeared-write appeared) Secondary School Exam. Certificate in support of Date of Birth (if it is not mentioned in the mark sheet of Secondary School exam.) Certificate in proof of desired reservation category (For SC/ST/ Schedule Tribal Area/OBC only) issued by the competent authority. Certificate of Physically Handicapped (for PH only) clearly mentioning the locomotor disability of lower limbs between 50% to 70% issued by the competent Medical Board as required in Information Booklet.
2. 3.
Certificate of eligibility under clause 3(C) printed in the Form A under the heading of Certificate No. 3 (Any one Certificate out of eleven must be filled in and signed by competent authority) The candidate applying under Defence Personnel of Rajasthan Origin must ensure that his/her priority (I to IV as mentioned in Information Booklet) is clearly mentioned in the Certificate Printed in the Form A. The candidate is also required to enclose photocopy of relevant certificate, if applying under Priority II or III. Two coloured photographs with name of candidate and his/her form number on the back of the photographs.
4.
Note : 1. Do not enclose any original certificate with Application Form. 2. All original certificates have to be produced before U. G. Admission Board at the time of Interview (Counseling)
YES/NO
Signature of Form Scrutinser Office of Convener RPMT-2011 Rajasthan University of Health Sciences , Jaipur
(8)
1. 2. 3. 4.
Affix your recent Coloured Photograph duly signed by the candidate and attested by a competent officer as explained in Information booklet
5.
Fathers Name
6.
7.
8.
R.P.M.T. Marks .
Signature of Candidate
(9)