N.K.P. Salve Institute of Medical Sciences & Research Centre and Lata Mangeshkar Hospital Digdoh Hills, Hingna Road, Nagpur — 440 019 Phone (07104) 665000,244291, Fax:(07104) 3061 1 1- mail: nkpsims1 @rediffimail,com/website : www.nkpsims.in NKPSIMS/Dean/Stud.Sect./_ 74) _/20 Date:-: 4/7/2020 NOTICE As per MUHS Nashik Circular no. MAVV/XP /1588/2020 Dt- 10-5-2020 all student’s appearing for First MBBS Examination to be held in September 2020 (2019-20 Batch) are hereby informed that they should submit examination form by email. Proforma of examination form is available at college website. (www.nkpsims.in) Nashik SrNo Examination Exam | FormFees | Total Subject Code Fees 1 | First MBBS, 3,450/- 20/- 3,470/- | Anatomy I O1101A Anatomy Il 01101B ~', «+ + | Physiology! 01102 Physiology 01102B Biochemistry 1 01103A Biochemistry I! __ 011038 Examination fees should be pay by RTGS / NEET in college account. Account holder Name :- Dean, NKP Salve institute of medical Sciences & RC Nagpur Account No :- 2997002100002457 Branch Name :- Punjab National Bank Branch :- MIDC, Hingna Road, Nagpur IFSC Code :- PUNB0299700 Type of A/c :- Current Account Last date of submission : 31% July 2020 To send (Name your file as Roll No-Name) (Eg: 106-Rakesh chavan) 1) Only sent receipt of RTGS/NEFT to accnkpsims@rediffmail.com 2) PDF of Exam form, Receipt of exam fees paid by RTGS and Marksheet of HSSC to studentsection50@gmail.com ‘ibe Aca DEAN N.K.P. Saive institute Of Med. Sciences & RC and LMH, NAGPUR‘Appendix-T (QQ tes aeuSesr fereu=1 rarities =nfSras MAHARASHTRA Us UNIVERSITY OF HEALTH SCIENCES, NASHIK UNDER-GRADUATE / POST GRADUATE EXAMINATION FORM Examination Form No. : The Controller of Examinations, College Code | MUHS, Nashik. Sir, T request permission to present myself at the ensuing Winter/Summer half of 20....... I furnish my details as stated below: (Css Courey INDIDATE’S NAME in Capital Letters (Strictly as per Class XII or GAZETTE Notification) : (Surname) (First Name) 2. MOTHER'S FIRST NAME in Capital Letters: 3. FATHER’S/HUSBAND FIRST NAME in Capital Letters: 4. Candidate's mailing address in CAPITAL Letters only: Besaneeseas 6. College Name: 5. State: 7._Email Address: 8. Gender MALE (] . Date of Birth : = Paste (do not staple) Paste (do nol staple) recent Photograph recent photograph (Size 35mmx 45mm) (size 35mmx 45mm) ‘duly attested by the ‘must not be larger than this Dean/PrincipalHead of the ‘box. Photograph should ‘nstituton. Photograph ‘nol be larger than ths box. should not be larger than ‘and not older than three this box and not older than months three months | Left Hand Thumb impression ATTESTED UNATTESTED ‘Signature of the Candidate In runing nd, wenin te box nly NOTE : It is to be ensured that this Photograph and Signature should match with the Photograph and Signature of Hall Ticket. 0. List of Documents/Items to be attached/ verified: 4 Document ae For MUHS 5 Pantculars sattached | Colloge No. Yesnto” | unsete, | Use only Photograph duly ated by the Dean/Pringpal Photocopy of marks statement of latest examination Photocopy of Eligbilty letter (Fox First year Students only] OR Tanster later (WApplcaES] STUDENTS, following document is also to be submitted: ‘Attendance Certificate of Research Methodology workshop [Loa book (for Fresh students) (SOR Copy Tor Medica’ FAGURY & Hard Copy Tor Ser Faculties, ‘Students passed out om other Universities, UG Degree certicale of respective Universly. NOTE: Incomplete Examination form and without documents wil be rejected by the Universi.11. Dress Code: Sr. | Particulars Yes/No¥ No. i Whether Candidate want to wear Cultural/Traditional Dress during the University Examinations. {CF Yes, it is mandatory to reamin present at Examination Centre before 01 hour of commencement of University examinations for proper frisking (checking)]._ Iwill be appearing for the following Subjects (for ‘Subject Name and Subject Code, please refer ‘Theory Time-Table _Bublished by the University on the website):- Subject eben ‘Attendance % S.No | codes Sete Theory | Practical] © HOD Name HOD Sign DECLARATION BY THE CANDIDATE * 1) Lam aware that, I have to fulfil crteria of attendance prescribed by the University up to ‘commencement of Examination, failing which { shall be held "NOT ELIGIBLE” and will not be allowed to appear for Examination, 2) Thereby declare that 1 have not availed of any attempt (including the present cne) in excess of the maximum attempts permissible by Central Council / University for the said examination (wherever applicable), 3) Thereby deciare that I have gone through the syllabus prescribed and relevant rules of Ordinance 1/2014 (amended) Heads of Passing which are applicable for the examination for which I am appearing and 1 accept the same without any challenge (wherever applicable). Reference Ordinance 01/2014 rule 59, 60 & 62 for head of passing and Grace Marks) OR as applicable from time to time, 4) I shall be responsible if my application form is rejected for any errors, wrong or incomplete entries made by me in the examination form. 5) Thereby declare that I shall not claim any concession on religious ground, 6) Tam not defying the criteria of the admission order. 7) Lam not admitted to the course after the cut-off date declared by the Uriversity for grant of terms. - | Date: sia ] Signature of Candidate in running hand (CERTIFIED BY THE HEAD OF INSTITUTION 1 certify that, ‘Shr/Smit/Kum. ~-» 15. & bonafide student ofthis college and has satisfactorily attended the classes and 1. that his/her attendance is not less than as prescribed by the Universty & respective council norms in lecure teaching and practical work, however, in case prescribed attendance is not fulfill up to commencement of examination, Hall ticket of the Candidate will be marked as “NOT ELIGIBLE” against the respective subject. 2. thatthe candidate has completed the academic terms and appeared in mandatory number of intemal assessment tests as per the university rues (wherever applicable). 3. that he/she is not admitted tothe course after the cut-off date for grant of terms. 4. that the candidate has completed house Job (For PG Orly wherever applicable) ‘5. that the information furnished by the said candidate is verified from his/her documents and that the candidate is Eligible to appear for University Examination, Place: I ate EVA] 2] 0 | Signature & Seal of the Dean/Principal%, Appendix-) Q) S4ereres; srrSreer ferewer rears .entSres MAHasseneee Os UNIVERSITY OF HEALTH SCIENCES, NASHIK UNDER-GRADUATE/ POST GRADUATE EXAMINATION FORM TEE The Controller of Examinations, College Code MUHS, Nashik. Sir, ue Pe py FRESH [—] REPEATER [—] (Please / Mark) I request permission to present myself at the ensuing ___Fi Winter/Summer half of 2017, I furnish my details as stated belo 1. CANDIDATE'S NAME in Capital Letters (Strictly as per Class XII or GAZETTE Notificati clal nl Plal tte! [olalnfels[ xl [s) fal ni xl al (Surname) (First Name) (Middie Name) 2. MOTHER'S FIRST NAME in Capital Letters: [p] al R] v| Al T| 1 Examination to be held in 3. FATHER’S/ HUSBAND FIRST NAME in Capital Letters: | s| 4] al N| K| Al R 4, Candidate's mailing address in et I A} PA] Ri T] ME] Ni T Nn als] H] 1] «| | Le | J T Pincode: 5.state: [wl al H] al Ral s| H] T] RI A ntact No.1 9] 6] s] 0] o| o| 7] 8] 5] 0 6. College Name:/ q Al al N| T Eloli|clalt] [cloliftlelde ULM BI 7. Email Address: ganesh@gmail.com Gender i MaLel y || FEMALE 9. Date of Birth : A] e [ee] (aus eine Date Left Hand Thumb impression ‘Slonature of the Cada in Goceet ‘fee ry Grant Medical Golege, Mamba! NOTE ; It is to be ensured that this Photograph and Signature should match with the Photograph and Signature of Hall Ticket. 10. List of Documents /Items to be attached / verified: 5 Documents |For For ae Particulars attached | college | MUHS X Yesiio_| Use only | Use only 7__| Photograph dy attested by the Dean/Principar Yes Verifies 2. | Photocopy of marks statement of latest examination. Yes. Verified 3. Of Eligibiliyletler (For First year Students only) OR Transfer eter W Applicable) Yes. Verified FORPS STUDENTS, folowing documents also to be submited Yes | Verified | 4. | Aitendance Certificate of Research Methodolog Yes. Verified “5. | Log book (orFean sudens) (Sof Copy tor Mesisr ove Hard Copy for other Faculties. Yes, fenfieg ‘Students passed out ‘rom other Universities, UG Degree certificate of respective Uni Yes. Verified [COTE FIncomplet Examination form and without docurtens wil be ejcied bythe Usteey —38-i. Code: Sr. | Particulars No. 1. ‘Whether Candidate want to wear Cultural/Traditional Dress during the University Examinations, [GF Yes, it ts mandatory to reamin present at Examination Centre before 01 hour of commencement of | No University examinations for proper frisking (checking)]. Iwill be appearing for the following Subjects (for Subject Name and Subject Code, please refer Theory Time-Table published by the University on the website):- Yes/No* For Fresh Students Only ie | tear Suhiecé Meme Trenance | HOD Name HOD Sign 1 Sua | Anatony —T8 50% 55% [DMA Patl — | Dynal 2 011028, | Physiology ~ I & % 60% [Dr S.RShah | erated 3 ai Biochemistry — I & IT 42% 70% | Dr. T. K. Kulkarni | éutéanaces Speciman- c copy 1) [am aware that, I have to fulfill criteria of attendance prescribed by the University up to commencement of Examination, failing which 1 shall be held “NOT ELIGIBLE” and will not be allowed to appear for Examination, 2) I hereby declare that I have not availed of any attempt (Includirig the present one) In excess of the maximum attempts Permissible by Central Council / University for the said examination (wherever applicable). 3) Thereby declare that I have gone through the syllabus prescribed and relevant rules of Ordinance 1/2014 (amended) Heads Of Passing which are applicable for the examination for which T am appearing and 1 accepfthe same without any challenge (wherever applicable). Reference Ordinance 01/2014 rule 59, 60 & 62 for head of passing and Grace Marks) OR as applicable from time to time. 4) T shall be responsible if my application form is rejected for any errors, wrong or incomplete entries made by me in the ‘examination form. 5) hereby declare that I shail not claim any concession on religious ground. 6) [am not defying the criteria of the admission order, 7) Lam not admitted to the course after the cut-off date declared by the University for grant of terms. Prace: [mul Ma] ala] | ] Ganpateg date: | of 1] of [7 2] 0] i] 9] Signature of Candidate in running hand _————— a CERTIFIED BY THE HEAD OF INSTITUTION certify that, Shri/Smt/Kum. Ganesh Shankar Ganpate is a bonafide student of this college and has satisfactorily attended the classes and 4) that his/her attendance is not less than as prescribed by the University & respective council norms in lecture teaching and Practical work, however, in case prescribed attendance Is not fulfill up to commencement of examination, Hall ticket of the ‘Candidate will be marked as "NOT ELIGIBLE” against the respective subject. 2) that the candidate has completed the academic terms and appeared in mandatory number of Internal assessment tests as per the university rules (wherever applicable). 3) that he/she is not admitted to the course after the cut-off date for grant of terms, 4) that the candidate has completed house job (For PG Only~ wherever applicable) 5) that the information furnished by the said candidate is verified from his/her documents and that the candidate is Eligible to appear for University Examination. Place: [Mu] Ml Bla! ok a Drpatd I vate: [0] 7] of 1/12] of a] 9 Signature & Seal of the Dean/Principal “39°