DECI,ARATION BY TI-IE PARENT / GUARDIAN

In the event of my Son/ Daughter lWard Shri/ Smti ......... being

admitted in any institution, I shall be responsible lbr his / her conduct and undertaken to pay his / her college
dues, hostel dues and other expenses during his / her studentship in the college, I also undertake to withdraw
him / her from the college, should the authorities concerned decided that such withdrawal is necessary in the
interest of the college or in the event of inability to pay his / her college or hostel dues in time or due to his / her
unsatisfactory result and attendance and conduct after clearance of all his / her dues if any and without claim-
ing any compensation from the Government or the college authorities.
I, further declare that there is no allegation of misconduct against my son / daughter / ward and
he / she has never been convicted for any oflbnce involving moral turpitude.
I, further declare that if any statement is proved to be false then the authority shall have right to
take legal action against me and my son / daughter for submitting false infbrmation and statements.

I certify that the particulars stated in this application by my son / daughter / ward are true to the
best of my knowledge and if it is proved that the information is fraudulent, I am liable to criminal prosecution

Signature of the gaz.etted officer in Signature of the parent/Guardian

presence of whom the parent / guardian
Fullnarne...
put his / her signature

Designation of the Offrcer. Seal of the oflice

INSTRUCTION TO ALL CANDID{IES

1) Candidate must produce thefllled-up Application Form along with all the relevant ceirtillcates in the
Annexures within the Application Form.
sisnature and counter sisnature as noted thcreon.
2) AII applicants shall hav"e to produce the original copies of the following documents along with their
completed Application Form at the time of counseling, if salled for.
a) Admit card and pass certificate of HSLC or equivalent examinations.
b) Marks sheet and pass certificate of HSSLC (Sc.) or equivalent examinations.
c) Caste certificate.
d) Permanent Residential Certificate.
e) Admit Card of the NEET.
f) Other Reserveation quota certificate.
3) The candidate must be physically present at the time of counsellig.

4) A set o1'self attested/signed photocopies of the above rnentionecl (at lnstnrction Point -2) original documents rnust
be submitted at the time of Counseling.

(m)
 SCHEDULE - I
ANNEXURE _ I
(As per the admission rule for MBBSIBDS courses this certificafe is fo be issued only to one i.e. in the
name of the candidate or his /her fatherlmother whoever is residing in Assam continuously for a
minimum period of 20 years).

PERMANENT RESIDENCY CERTIFICATE OF CANDIDATE OR HIS/HER

FATHER/MOTHER

(Certificate of 20 years of continuous Residency in Assam)

Signature of Deputy Commissioner or his/her authorized Officer

of the concerned District

Date:
FullName of the Certifying Officer.
 qCHEDULE. I
AI.',{NEXUBE - II
CERTIFICATE OF STUDY IN ASSAM BY THE CANDTDATE
(Separate Certificate in this format shallhave to be submitted if studied at more than one school.
Please do photocopies of this format accordingly before filling it up)

Name of Candidate :

Name of Father :

Name of Mother :

Residential Address :

Certified that the above named candidate/person has studied in my school and his/her
particulars during his/her study in my school as obtained from school records is given below -

Date of Admission :

Class in which admitted :

Class in which candidate left school :

Date of leaving School :

Reason for leaving School :

l. Completed course
2. Transferred to other School
3. Any other reason

The information provided above are true to my knowledge and belief and records.

Full Signature of the Head Master/Principal

Seal with date . .

Ful I Name of the Head Master/Principal..............

INSTRUCTION:
Certificate without the signatures as specified above shall not be accepted.
 SCHEDULE. I
AI$NEXURE - III

CERTIFICATE OF CASTE FOR THE CAI{DIDATES BELOING TO

oBc/MoBC CATEGORY (NON CREAMY LAYER)
Name of Candidate :

Name of Father :

Name of Mother :

ResidentialAddress : Village: ..................

PO............,..

PS................

Sub-Division
District........
PIN..............

Certified that the above named candidate/person belongs to Other Backward Classes/ More
Other Backward Classes and his/her Sub-Caste is........... and community is

This is also certified that the above named person falls under the category of Non Creamy
Layer of OBC/MOBC.

This certificate is issued to the candidate after making proper enquiry to his/her caste status as
per prevailing rules of Assam and guidelines issued by Govt. of India from time to time.

Signature of the ldentifying Authority

FullName of the Identifying Authority
Date:............

Countersigned by the DC / SDO of the concemed

District/ Sub-Division

Full Name of the Certifying Officer

INSTRUCTIONS.i
a) Sub caste and/ or Community in the certificate must be mentioned.
b) Certificate without signature of both the Authorities / Officers shall not be accepted.
c) Signature of any one of the following ldentifying Authority is a must-
(i) Chairman of Sub-Divisional Dev. Board for the Welfare of the Other Backward Class within
respective Sub-Division.
(ii) Member of All Assam State Advisory Council for the Welfare of the Other Backward Classes
within the respective District to which the Member belongs.
(iii) President i Secretary of All Assam Other Backward Class Association within the jurisdiction
concemed.
(iv) President / Secretary of DistricVSub-divisionalOther Backward Classes Association within
the respective jurisdiction
 SCHEDULE - I
ANNEXURE - IV
CERTIFICATE OF CASTE FOR THE CANDIDATES BELOING TO
SC CATEGORY

Name of Candidate :

Name of Father :

Name of Mother :

Residential Address : Village: ..............

PO

PS.

Sub-Division

District
PIN

Certified that the above named candidate/person belongs to Scheduled Caste and
his/her Sub-Caste is ..,.............. and community is ............

This certificate is issued to the candidate after making proper enquiry to his/her caste status as
per prevailing rules of Assam and guidelines issued by Govt. of India from time to time.

Signature of the Identifying Authority

Full Name of the ldentifying Authority
Date with seal..............
Signature of the Sub-Divisional Officer of the
concerned Sub-Division
Date with seal

Signature of the DC of the concerned

District

Date with seal .............

INSTRUCTIONS-
a) Sub caste and/ or Communify in the certificate must be mentioned.
b) Certificate without signature of both the Authorities / Officers shall not be accepted.
c) Signature of any one of the following ldentifying Authority is a must-
(i) Chainnan of Sub-Divisional Scheduled Caste Dev. Board.
(ii) President / Vice-President of the Assam Anusuchit Jati Parishad.
(iii) President of District level Assam Anusuchit Jati Parishad.
(iv) President of Sub-Divisional level Assam Anusuchit Jati Parishad.
(v) President / Vice-President of All Assam Mali Samaj.
(vi) President of District Committee of All Assam Mali Samaj.
(vii) President of Sub-Divisional Committee of All Assam Mali Samaj.
(viii) PresidenVSecretary All Assam Schedule Caste Dhobi People Welfare Council.
 SCHEDULE. I
ANNEXURE. V
CERTIFICATE OF CASTE FOR THE CANDIDATES BELOING TO
sT(Py sT(H) CATEGORY

Name of Candidate :

Name of Father :

Name of Mother :

ResidentialAddress : Village: ................

PO...............

PS................

Sub-Division
District........
PIN..............

Certified that the above named candidate/person belongs to (Name of the tribe)
Tribe which is recognized as ................
... under the Constitution (Schedule Tribes) order 1950 as amended from time to time.

This certificate is issued to the candidate after making proper enquiry to his/her caste status as per
prevailing rules of Assam and guidelines issued by Gov1. of India from time to time.

Signature of the President/Vice-President of

All Assam Tribal Sangha/ District Unit of Assam Tribal Sangha

Full Name of the Signatory.................

Seal with Date:

Counter Signature of the DC of the concemed

District

Seal with Date:............

INSTRUCTION:- Certificate without signature of both the Authorities / Officers shall not be accepted.
 SCHEDULE - I
ANNEXURE - VI
CERTIFICATE FOR TGL/Ex- TGL COMMUNITY

This is to certifu that Shri / Smti

son / daughter of Shri / Smti

Village P.S. ........... Sub- Divn.

Dist........... of Assam belongs to the TGL / Ex-TGL Communities of Assam.

Counter Signature of Director of Tea Signature of Deputy Commissioner/

Welfare Government of Assam his authorised signatory ofthe Concerned
Seal with Date:.......... District
Sealwith Date:

INSTRUCTION:- Certificate without signature of both the Authorities / Officers shall not be accepted.
 SCHEDULE - I
AI\NEXI]RE - VII
CERTIFICATE IN CASE OF CANDIDATE APPLIED AGAINST CHAR AREA QUOTA

This is to certify that Shri / Smti. ..son/daughter

P.O. ........... under P.S. ........... .................of District

belongs to a Socially, Economically and Educationally Backward family ordinarily residing at
which is covered by the Assam State Char Area Devlopment Authority.
The name of the father / mother of Shri Smti./ is in the
voter list prepared by the appropriate authority L.A.C. and in the
village........ at Serial No. ........... of the voter list published
in the year

Signature Signature of DC / SDO ( C ) of

Concerned District / Sub-Division
Designation
(Assam State Char Area Development Authority )

( Office Seal) ( Office Seal)

INSTRUCTION:- Certificate without signature of both the Authorities / Officers shall not be accepted.
 SCHEDULE - I
ANNEXURE - VNI
(Certificate for reservation of son / daughter of Ex-servicemen
/ Serving Defence Personnel hailing from Assam)

This is to certify that Sri ...... father

of Shri/ Smti . under
P.O. .......... .. P.S. ..................sub-division in
the district of .............. ....has served / is serving under the lndian Army / Navy / Airforce in
the rank of ..............

Counter Signature of Signature of Competent

Director of Sainik welfare, Assam Authority

Sealwith Date Sealwith Date

INSTRUCTION:- Certificate without signature of both the Authorities / Officers shall not be accepted.
Competent Authority in case of Ex-Servicemen is the Director, Sainik Welfare, Assam and Competent
Authority in case of Serving Defence personnel is the commanding officer of the concerned unit of
Army/Navy/Airforce.
 SCHEDULE. I
AI{NEXURE - IX
CERTIFICATE OF SON / DAUGHTER / BROTHER / SISTER OF PERSON KLLLED
IN EXTREMIST WOLENCE OF ASSAM
(strike off which is not applicable)

Name of Candidate :

Name of Father :

Name of Mother :

Residential Address : Village: ................

PO...............

PS................

Sub-Division
District........
PIN..............

Certified that the above named candidate/person is the Son/ Daughter /Brother/ Sister (strike
off which is not applicable) of Late (Name of the person
killed in extremist violence) who was killed in extremist violence in the year

Division....... ...............in the district of.............................,.... on (Date).....

Signature of DC / SDO ( C ) of Concerned

Signature of Police Officer
District / Sub-Division
Case No.....

under P.S.

Seal with Date:............

INSTRaCTION:- Certificate without signature of both the Authorities / Officers shall not be
accepted.
 SCI-IEDULE-II-A
(DEED OF AGREEMENT)

(To be executed by all Students admitted into MBBS course)

THIS DEED OF ACREEMENT is nrade on this.... ......day of

..20.......... between the State of Assam, Health and Farnily Welfare Departrnent to be
represented by Sri ..... S/O

.. .. . .. aged about . ... Years, presently holding the

post of the Principal.. ......Medical College,
.....in tlre Health arrd Family Welfare Departrnent, hereinafter to be referred as the First
Party and (Nanre of tlre str"rdent). S/O

aged aboLrt ...years, resident of

Vill/Tor.vn. PO.... PS.

Dist. . ......State. hereinafler refbrred as Second Par1y.

AND WHERIIAS the Secorrd Party has beerr admitted in the MBBS Course in the

.. Medical College, ...... and shall cornplete the Four

and half years plus one year Internship Course.

AND WHEREAS the Second Party shall bear only the adrnission fees, hostel fbes, and
other charges fbr the course and the First Party shall give the rnonthly stipend to the Second Party
during the period of Irrternslrip Trairring on completion of MBBS Course.

AND Wl-IEREAS the Government of Assanr shall incur huge expenditure f}om State
Exchequer for the plrrpose of imparting education to the Second Party in pLrrsuing the MBBS Course
in a State Medical Colleges in Assam.

AND WHEREAS in the interest of public service, the First Party has decided to give
admissiorr to the Second Party in tlre MBBS Course at

",,0
,n", bear the .;0.;,",
"r
ff::"::i"1r"", o,r,", ,nu, ,r,.
"o ",rri",
;.r:'r:;:::::iil;
charges, in pursuing the said course .
NOW, THEREFORE THIS AGREEMENT WITNESSES THE FOLLOWING TERMS AND
CONDITIONS:

L That, after completion of his/her MBBS Course the Second Party shall serve the State
Covernment for minimirm period of 5(five) years upon offer of appointment in any State

Government Service in the Health and Allied sector including agencies/institutions under
NHM and/or any other State/Central Government sponsored Scheme/s or in Lieu thereof
l(one) year rural service on completion of MBBS Course.

2. That, the First Party shall have the authority to utilize the service of the student i.e. the Second
Party in any Hospital/Medical Institutions within the State of Assam where there is necessity of
a Doctor in the interest of public service.

3. That, in case of any breach of the terms and conditions as stated hereinabove, the Second Parly
shall be liable to pay an amount of Rs.30,00,000.00 (Rupees thirty lakhs) only as compensation
to the First Pafty, i.e. the Government of Assam, Health and Farnily Welfare Department.

4. That, in case of failure to pay the compensation as mentioned above, the First Party shall be at
liberty to file a Money Suit and/or take any other appropriate legal action against the Second
Party in the competent court to recover the same at the risk and cost of the Second Party.

lN WITNESS WHERE OF the parties hereto have signed, sealed and delivered these presents

on the day, month and year mentioned above.

Witness: (Signature of the First Party)

l.

(Signature of the Second Par-ty)

2.

l0
 SCTTEDULE-II-B
(DEBD OF AGREEMENT)

(Io be executed by all Students admitted into BDS course)

THIS DEED OF AGREEMENT is made on this..... .....day of

..20.......... between the State of Assanr, Health and Fanrily Welfare Departmerrt to be
represented by Sri ..... S/O

......, aged about . ... Years. presently lrolding the

post of the Principal, Regiorral Derrtal College. Guwahati, Assam in the Flealth and Family Welfare
Depaftment, hereinafter to be ref'erred as the First Party and (Name of the student).
S/O aged about

...years, resident of Vill/Town. PO....

PS..... Dist. .......State. hereinafter
refbrred as Second Party.

AND WHEREAS the Second Party has been adrnitted irr the BDS Course in the Regional

Dental College, Guwahati and shall complete the Four years plus one year lrrternship Course.

AND WHEREAS the Second Party shall bear only the adrnission fees, hostel fbes, arrcl

other charges tbr the course and the First Party shall give the rnonthly stipend to the Second Party
during the period o1'lnternship Training on cornpletion of BDS Course.

AND WHEREAS the Covernment of Assam slrall incur huge expenditr"rre fiorl State

Exchequer for the purpose of irlparting educatiorr to the Second Party in pursuing the BDS Course in

Regional

Dental College, Guwahati, Assanr.

AND WHEREAS in the interest of public service, the First Party has decided to give
admission to the Secorrd Party in the BDS Course in the State of Assam and shall bear tlie experrses of
his/her education, other than the admission fees. hostel fees and other charges, in pursuing the said
coLlrse.

ll
NOW, TI-IEREFORE TI{IS AGREEMENT WITNESSES TIIE FOI,LOWING TERMS AI{D
CONDITIONS:

I . That, after completion of his/her BDS Course the Second Party shall serve the State

Govemrnent fbr minirnum periocl of 5(1ive) years Llpon ofl-er of appointrnent in any State
Governnrent Service irr the Health and Allied sector including agencies/institutions under
NRHM and/or any otlrer State/Central Covernment sponsored Scheme/s or in Lieu thereof
l(one) year rural service on conrpletion of BDS Course.

2. That, the First Party shall have the authority to Lrtilize the service of the stLrdent i.e. the Second
Party in any Hospital/Medical Institutions within the State of Assam wlrere there is necessity of
a Doctor in the interest of public service.

3. That, in case of any breach of the terms and conditions as stated hereinabove, the Second Party
shall be liable to pay an arnount of Rs.20,00,000.00 (Rupees twenty lakhs) orrly as

compensation to the First Party, i.e. the Governr.nent of Assanr, Health arrd Farlily Welfbre
Department.

4. That, in case of failLrre to pay the compensation as rnentioned above, tlre First Party shall be at
liberty to file a Money Sr-rit and/or tal<e any other appropriate legal action against the Second
Party in the competent court to recover the same at the risk and cost of the Second Party.

IN WITNESS WHERE OF the parties hereto have signed. sealed and delivered these presents

on the day, rnonth and year mentioned above.

Witness: (SignatLrre of the First Party)

t.

(SignatLrre of the Second Party)

2.

12