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    West Bengal Application Form

    Uploaded by

    mahesh
    This document is an application form for admission to various postgraduate medical, dental, and post-doctoral courses offered by the West Bengal University of Health Sciences. It requests information such as the candidate's name, address, academic qualifications, registration details, and other relevant information. The instructions specify the documents required to be submitted along with the application based on the course applied for. Candidates are advised to read the guidelines in the information booklet carefully before filling the form.

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    Download as PDF, TXT or read online from Scribd

    West Bengal Application Form

    Uploaded by

    mahesh
    5K views5 pages
    This document is an application form for admission to various postgraduate medical, dental, and post-doctoral courses offered by the West Bengal University of Health Sciences. It requests information such as the candidate's name, address, academic qualifications, registration details, and other relevant information. The instructions specify the documents required to be submitted along with the application based on the course applied for. Candidates are advised to read the guidelines in the information booklet carefully before filling the form.

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    West Bengal Application Form

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    This document is an application form for admission to various postgraduate medical, dental, and post-doctoral courses offered by the West Bengal University of Health Sciences. It requests information such as the candidate's name, address, academic qualifications, registration details, and other relevant information. The instructions specify the documents required to be submitted along with the application based on the course applied for. Candidates are advised to read the guidelines in the information booklet carefully before filling the form.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    5K views5 pages

    West Bengal Application Form

    Uploaded by

    mahesh
    This document is an application form for admission to various postgraduate medical, dental, and post-doctoral courses offered by the West Bengal University of Health Sciences. It requests information such as the candidate's name, address, academic qualifications, registration details, and other relevant information. The instructions specify the documents required to be submitted along with the application based on the course applied for. Candidates are advised to read the guidelines in the information booklet carefully before filling the form.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 5

    Form No:

    Price: Rs.750/-

    Roll Number(For Office Use Only)

    WEST BENGAL UNIVERSITY OF HEALTH SCIENCES


    For Official Use (Counselling) APPLICATION FOR ADMISSION TO DIFFERENT Signature of the Applicant
    POST GRADUATE MEDICAL, DENTAL DEGREE/
    1.Order of Merit ………. DIPLOMA & POST DOCTORAL COURSES
    Affix Recent
    MD/MS MDS DM/MCh MCH Passport Size
    2.Counselling Date ……..
    DIPLOMA (3 Yrs) (6 Yrs) Attested Photograph
    3.Course………………..

    4.Institution…………….. MARK WITH TICK ( ) IN THE BOXES


    WHERE APPLICABLE
    5.Controller……………. Application form should be filled in by candidate after
    going through the guidelines given in the Information
    Booklet.
    Application form should be filled in BLOCK LETTERS
    Signature of Gazetted Officer
    ONLY with BLUE/BLACK ink

    Name in Full
    (In Block Letter)

    Father’s/Mother’s
    Name:
    Mailing Address:

    District
    State
    City/Vill
    Pin
    Permanent Address:

    District
    State
    City/Vill
    Pin
    Telephone Date of
    DD / M M / Y Y Y
    Number: Birth:
    Y

    Whether you belong to SC/ST All India (MD CM) WBHS


    SC ST Govt. Sponsored Whether you are in WBMES
    General service in any of the WBDS
    following
    Nationality: OTHERS
    Type of MCI DCI WBMC WBDC Oth. Regular
    Registration: Type of service Adhoc
    Registration No : Male
    Year of Registration: Sex
    Female
    Registration Type : (Permanent / Handicapped: Y/N
    Provisional)
    Completion of Internship (1 year) Yes / No Handicap Card No:
    Completion of PRCA(6 Months) Yes /No
    From Date To Date Institution

    Foreign MCI /DCI Clearance Sponsorship Ministry of No Objection from Ministry of External
    Student Home, GOI Affairs, GOI
    YES/NO YES /NO YES /NO YES / NO

    Are you at present undergoing or have undergoneany


    Postgraduate Degree Diploma course Ph.D

    Yes No Yes No Yes No


    Give Details: (Subject, Course, Institution, University, Session)

    Have you applied for admission or been admitted /selected / enrolled in any course in any Institution during
    this session? If Yes Give Details (Subject, Course, Institution, University, Session)

    Academic Qualification (s) : M.B.B.S / B.D.S


    MBBS/BDS Name of Institution:
    Year of Passing No of Total Marks % University Gold
    Attempts Marks Obtained Marks Medal/Honours with
    Subject
    1st Professional

    2nd Professional

    3rd Professional
    (Part I)
    3rd Professional
    (Part II)
    4th Professional

    Signature of the candidate

    (Counter Signed)
    Academic Qualification must be Countersigned by Head of the Medical Institution / or by a Gazetted Officer)
    Form No. : <self numbered>

    Additional Information
    (To be filled in only by those applying for admission to DM/MCH Courses (3 Year))
    Course Applied For Subject

    DM MCH
    Academic Qualification (s) : M.D / M.S
    MD/MS Name of Institution:
    Year and Month of Year and Month of No of Attempts
    Admission Passing

    M M Y Y Y Y M M Y Y Y Y

    I do hereby declare that all the statements made by me in this application (including additional particulars)
    are true, complete and correct to the best of my knowledge and belief.
    I do hereby submit the application form as per the instructions.
    In case it is detected at any point of time that any of the statements made by me in this application
    involves suppression or distortion of truth or that the application is not supported by any of the relevant
    documents as mentioned in the instructions, my application for admission shall be liable to be cancelled
    without further reference to me. I shall be bound to abide by the stipulations laid down by the University
    for the purpose of admission to the Degree/Diploma/Post doctoral Courses for the ensuing session.

    Date
    Place
    Signature in full of the candidate

    CERTIFICATE FROM THE HEAD OF INSTITUTION /ORGANISATION


    For candidates engaged in study in any other courses,
    or in service other than W.B. H.S./W.B.M.E.S/W.B.D.S/W.B.G.S,
    or under going housemanship training

    Certified that Sri/Sm……………………………………………………………………….holds the post of/ a


    student of…………………………………………………...in the Department of………………………………
    Since…………… .. in this Institution/organization. I have no objection to his/her application being considered
    for admission to the Postgraduate Medical Degree/Diploma/Dental Degree/Post-doctoral course of the West
    Bengal University of Health Sciences for the ensuing session.

    No………………………………….. Signature………………………………………………..

    Place………………………………... Designation…………………………………………….

    Date………………………………… Office Seal……………………………………………...


    Instructions (Read it carefully):
    1. One self-addressed envelop (9” x 6”) (without affixing postal stamp) to be enclosed with the
    application
    2. For MD/MS/Diploma/MCh Neurosurgery(6 year)/MDS Courses
    a. The applicants need not submit any attested copies of supporting documents along with their
    application form.
    b. Only the qualified candidates of MD/MS/Diploma/MCh Neurosurgery(6 year)/MDS courses
    have to submit attested copies of all supporting documents along with originals for
    verification as mentioned in the information booklet .

    3. For DM/MCh (3 year) Courses:


    a. The applicant for DM/MCh 3yr Courses have to submit the attested copies of following
    documents along with his/her application form in the order given below
    i. University Registration Certificate
    ii. Permanent medical registration certificate
    iii. Chance/Attempt certificate –UG and PG
    iv. Internship/PRCA training completion certificate
    v. Marksheet of MBBS Examination (all professionals)
    vi. University gold medal/honours certificate
    vii. MD/MS certificate and Marksheet
    viii. Proof of publications in indexed journals
    ix. Proof of age
    x. Employment certificate from the controlling officer(for WBHS/WBMES candidates)

    The application should be submitted to the Office of the Controller of Examinations,WBUHS at DD-
    36, Sector-I, Salt Lake, Kolkata-700064 within the time notified in the Information Booklet.
    Form No: < self numbered >

    1. Candidate’ s Name in Capital Letters (as per the last professional examination)

    Course applied for:


    MD/MS MDS DM/MCh MCh
    DIPLOMA (3 Yrs) (6 Yrs)

    Affix Recent
    Passport Size
    Photograph

    1.Do not attest


    2. Do not write
    anything on the face
    of the photograph

    Signature of the Candidate


    (Do not write anything in this space)

    Form No. : <self numbered>

    Received an Application Form from Dr.…………………………………………..………………………………


    For Selection Test of MD/MS/PG Diploma/DM/Mch/Mch (6 years)/MDS, 200…..

    Signature with Official Seal and Date

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