SAURASHTRA UNIVERSITY.

Examination Form SECOND YEAR M.B.B.S. (NEW /OLD)

SR.NO SR. NO OF APPLICATION

(A) TO BE FILLED BY THE COLLEGE :

COLLEGE NAME : SHRI M.P.SHAH GOVT. MEDICAL COLLEGE, JAMNAGAR

To : JAMNAGAR TALUKO : JAMNAGAR POST : JAMNAGAR DIST : JAMNAGAR

PROGRAM COURSE NAME : FACULTY :

SR.NO OF APPLICATION : COLLEGE CODE : 13006
CENTRE CODE : 1306 APPEARING IN EXAM :
ENROLLMENT NO : ENROLLMENT DATE :
ELIGIBILITY CERTI NO : ELIGIBILITY CERTI DATE :

(B) TO BE FILLED BY THE STUDENT :

SURNAME :
CANDIDATE
NAME :
PASSPORT SIZE
FATHER / HUSBAND NAME :
PHOTOGRAPH
WITH SIGNATURE

SEX : (¡ ) : MALE : FEMALE ; CATEGORY ; SC : ST : SEBC : OTHER : PH :

PERMANENT ADDRESS : CORRESPONDANCE ADDRESS :

TO : ……………………………………………TALUKA :……………………………… TO : ……………………………………………TALUKA :………………………………

DIST : …………………………………………….POST : ……………………………….. DIST : …………………………………………….POST : ………………………………..

PIN : ……………………………………….STATE : ………………………………………. PIN : ……………………………………….STATE : ……………………………………….

EXAM TYPE : WHOLE : PART : ANSWERING LANGUAGE : GUJARATI : ENGLISH : HINDI :

MOBILE NO : E –MAIL ADDRESS :

DETAILS OF PREVIOUS EXAM ATTACHED MARKSHEETS OF ALL PREVIOUS EXAM :

SR. COURSE SEMESTER EXAM MONTH & OBTAINED TOTALM ATTEMPT % RESULT SELF ATT ESTED MARKSHEET
NO. YEAR YEAR MARKS ARKS NO. ATTACHED :

(¡ ) (X)

01 H.S.C.

02

03

04

05

06

I HAVE TO APPEAR IN THE FOLLOWING SUBJECTS.

SECOND YEAR M.B.B.S. ( NEW/ OLD).
TICK (¡ ) OR (X)
SR.NO. CODE NAME OF SUBJECT
( NEW COURSE ) (OLD COURSE )

5
6

7
ENCLOSED : (¡ ) ABOVE SELF ATTESTED MARKSHEET NO
 3. EXAMINATION PARTICULARS
I request exemption from the following subject/s as I have obtained necessary marks for
Examination in the subject/s concerned i.e. 50 % or marks as prescribed form time to time in
Subjects/ held in the year mentioned against them. An attested copy of Marksheet is attached
herewith.
Month & Year Subject Marks Obtained Seat No. University Centre Result

Place : ……………………………………… Yours faithfully

Date : ________________________________ ……………………………………………

S Candidate’s Signature

Certificate to be signed by the Principal of the College at which the candidate has studied
I certify that Shri/Smt./Kum ____________________________________________________________
has kept one term in my college by attending______________________ days out
of__________________ days. He/She is a student of our college studying in FIRST YEAR has successfully
completed the U.G.C. ENVIRONMENTAL STUDY COURSE as prescribed wide its D.O. Letter No.F.13-
1/2000(EA/ENV/COS-I), Dt. 07-08-2014 (Ref. A.K./PARYAVARAN/1124/2015 Dt. 02/12/2015.)

1. The attendance report for the respective term will be sent to the University by 20th March,201.

2. I further certify that to the best of my knowledge and behalf; he/she is a person of good conduct and that is
he/she has my permission to present himself/herself at the ensuing SECOND YEAR. MBBS Examination
whichever applicable.

3. I Certify that he/she (a) has during this/previous academic year undergone medical examination held by
authorized persons and (b) (i) as per O.182 he/she has satisfactory gone through the course of physical
training periods during the academic year OR (ii) he/she regularly taken part in athletics of major sports
during academic year as a member of the University athletics OR sports teams OR (iii) he/she is a member
of the National Cadet Corps or he/she has been exempted from undergoing the physical training (1) on
medical grounds as per rules in force OR (2) on other grounds laid down by the University.

4 I also certify that the statements of the candidate regarding EXEMPTION claimed at the examination in a subject/s
as above is/are correct and eligible for the exemption and he/she has not appeared in that / those subjects.

5. I certify that he/she is eligible to appear for the respective exams as per the rules of the university, M.C.I. RULES.
PLACE:…………………………………………………………………………………………………………………………………………………PRINCIPALSIGNATURE:……………………………………………………

DATE: : ……………………………………… PRINCIPAL’SNAME____________________

+ To be struck off where it is not applicable.

+ Write your name in English in correct spelling. The spelling of the name written here shall be the spelling for
University records and no change therein can be made afterwords. Please attach con attested copy of the
statements of marks in supports of exemption claimed and passing the previous Examination.
# Insert one of the centers announced by the University for this examination. Centre change is not allowed.
Examinee Assurance.
1 I shall not bring any kind of written material or written notes and would not write anything related to exam (anywhere) on any
object in the examination hall during the time of examination.

2. I shall not converse to other examinees, and shall not try to send any message or would not misbehave which can create
disturbance in the examination hall during the time of examination.

3. I shall not indulge in any act of misbehavior in the examination hall.

4. I shall not carry the main supplementary written or blank answer sheets given to me while I leave the examination hall after the
examination gets over, nor shall I indulge in any such activity which would lead to attempting the examination from outside the
examination hall. I am aware that such activities might lead to disciplinary actions resulting in being expelled from the
examination hall and getting reported to the university.

5 I am aware that I shall be liable for punishment if I indulge in any undesirable activity or misbehave with the Junior Supervisor, or
Senior Supervisor or any other University official on duty in the examination hall.

6. I hereby furnish the assurance that I shall act in accordance with all the University rules and regulations regarding examination
and would be liable for any punishment the University deems fit for the violation of the said rules and regulations.

7. I hereby furnish the assurance that I shall follow all the instructions given on the answer sheet during the time of examination.

8. I hereby assure that I am eligible to appear for the respective exam as per rules of the university, M.C. I. RULES.

___________________ __________________
Examinee’s Signature 2 Principal’s Signature and Stamp
DATE
PROVISANLY SUBMITTED