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STATUTORY WARNING: RAGGING IS AN OFFENCE & PUNISHABLE AIPMET Roll No. Thumb Impression (Females: Right Hand, Males: Left Hand) Marks obtained in AIPMET Rank Category under which you wish to be considered (Tick the correct Cat.) 1. Govt. Seats: (A) General (B) SC/ST
(C) BC (D) Other (Please specity )
2. Management Seats: (A) General (B) SC/ST (C) BC
3. NRI Seats: (A) (Cat.I) (B) (Cat.II)
a. Category I:First preference shall be given to the Foreign Indian Studnets, who have ancestral background of the State of Punjab. b. Category II:Second preference to Non-Resident Indian Students having ancestral background of other states of Indian other than Punjab/Union Territory of India. Name (IN BLOCK CAPITALS) Father’s Name (IN BLOCK CAPITALS)
Mother’s Name (IN BLOCK CAPITALS)
Annual income of parents Mother __________________ Father _____________________ from all sources
Blood Group* Sex: Male Female
Date of Birth Date Month Year
Age as on ( Dec 31, 2013 ) Place of Birth Address for correspondence_________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Telephone No. with Code _______________________ (Fax No. if any) _________________________
Mobile No. (Father)_________________________(Mother)___________________________(Student)______________________
(E-mail Id (Father)________________________________________(Student)__________________________________________
Permanent Home Address ___________________________________________________________________________________
___________________________________________________________________________________
__________________________________________________________________________________
Telephone No. with Code _________________________ (Fax No. if any) _______________________
Tick √ Residence Status* Punjab State Other State
YY MM DD
Signed
Passport
Size
Photograph
Sr. No.__________
GENESIS INSTITUTE OF Sr. No…………..
DENTAL SCIENCES & RESEARCH
(Dental College & Hospital) Admission Form
Ferozepur – Moga Road, Ferozepur, Punjab B.D.S. BATCH 2015-20
Admission Form
Sr. No.__________
Academic Qualifications (10+2 details)*
Examination Board/university Roll No. Year Subjects Marks
Max. Obtained %age
Matriculation
10+2
Physics
Chemistry
Biology
English
Total PCB=
10+1 and 10+2 from Punjab* Outside Punjab
List of Enclosures (Place in sequence in student file)
i) 10
th Certificate (For Date of Birth) along with DMC (if applicable) bearing father, mother’s name and date of birth.
ii) Qualifying Examination Details Marks Card (10+1) iii) Qualifying Examination Details Marks Card (10+2) iv) 10+2 regular student certificate from Principal of the school where last studied v) Migration Certificate (in case candidate passed 10+2 exam from a board other than PSEB) vi) AIPMET- 2015 Admit Card/Result Card vii) Character Certificate from Institute last attended, school leaving certificate as per guidelines in Para 6.1.6 of
MCI, Draft Notification. viii) Punjab State Domicile Certificate/Residential Proof ix) Gap year affidavit (if any) x) SC/ST/BC/ J & K Certificate (Reserved Category Certificate) xi) Eligibility Certificate (In case of NRI Candidate)
xii) Declaration of Student/ Parents/ Guardian. xii) Passport size photograph.
xiii) Photocopy of the Admit Card with Thumb impression (AIPMET 2015 LTI (Males) & RTI ( Females). xiv) Undertaking from the student regarding not been disqualified by any Board/University xv) Provisional Admission slip of selection by Central Admission Committee xvi) Affidavit of Undertaking by Candidate & Parent as prescribed by MCI Institute
xvii) Previous Medical record if any & signed undertaking by student & parent
that nothing is concealed.
(In case of any chronic problem, parents must hand over photocopy of relevant documents & advice in writing for
any precautions/first aid to be rendered / or any other specification).
Note: Original documents will be seen at the time of counseling.
Signature of Student
Sr. No.__________
DECLARATION OF THE APPLICANT
I, _______________________________ Son/Daughter of ____________________________ do solemnly affirm and declare that the particulars given above for admission to 1
st year BDS Courses for the session 2015-2020 in Genesis Institute of Dental Sciences &
Research, Dental College & Hospital, Ferozepur, Punjab are true and correct to the best of my knowledge and nothing has been concealed. I understand that my admission is provisional and it will be at my own risk, subject to the approval of Baba Farid University of Health Sciences, Faridkot, Punjab. It is further understood, that if at any later stage it is discovered that any particulars given above in my admission form is false or not in accordance with policy guidelines laid vide State Government notification, my admission will stand cancelled automatically. I undertake that in case I am admitted, I will abide by all the conditions and will strictly follow the rules and regulations put in force from time to time by the institution. I further undertake to observe discipline and follow the instructions issued by the authorities. The College will have full authority to expel me for misbehavior, misconduct, repeated failures in examinations or for any unworthy act on my part. I shall strictly adhere to Hon’ble Supreme Court, MCI / DCI and other rulings regarding Ragging, which has been clearly amplified in the Prospectus issued by Baba Farid University of Health Sciences & Genesis Institute of Dental Sciences & Research. I have also read and assure strict adherence to anti-ragging guidelines of MCI, a copy of which has been obtained along with prospectus. In case of any violation, I will abide by the decision of the institute which will be final & binding.
Signature
Name of the Applicant
Undertaking by Parent/ Guardian
I certify that the particulars given by my ward __________________________ in the Admission Form are correct. I fully understand the financial implications/obligations involved in case my ward is admitted and I undertake to pay the tuition and other fees payable to the institute under the rules.
1. I declare the negative traits/health of my ward as given in the character certificate/ medical certificate. In case of any aggravation, I will take action as advised by the institute authorities.
2. I have read the MCI regulations whose copy I have obtained along with the prospectus and in case of any violation
by my ward, will abide by the ruling of the institute which will be final and binding.
Signature
Name of the Father/ Guardian/ NRI Sponsor (in case of NRI Candidate)
----------------------------------------------------------------------------------------------------------------------------------
Recommendation
Principal
GENESIS INSTITUTE OF
DENTAL SCIENCES & RESEARCH (Dental College & Hospital)
Ferozepur-Moga Road, Ferozepur (Punjab)
Name of Student:
(Block Capitals)
Roll No.:
(To Be Filled By Academic Clerk)
Identification Mark: ____________________________________________
Blood Group: ___________________________________________
Local Contact Address: ____________________________________________
____________________________________________
Contact Number: Tele No. ___________________________________________
Mobile (Father)_____________________________________
(Mother) ____________________________________
(Student)____________________________________
E-Mail ID _____________________________________________
Signature of Student
Signature of Issuing Authority
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Name of Student:
(Block Capitals)
Roll No.:
(To Be Filled By Academic Clerk)
Batch _______________________________________________
Date of Birth ________________________________________________
Identification Mark: ________________________________________________
Blood Group: ________________________________________________
Father’s Name ________________________________________________
Permanent Address ________________________________________________
Contact Number: Tele No. ________________________________________________
Mobile (Father) _______________________________________
(Mother) ______________________________________
(Student)_______________________________________
E-Mail ID: _________________________________________________
Signature of Student
Signature of Issuing Authority
OUT PASS APPLICATION FORM
I CARD APPLICATION FORM
Sr. No.__________
Genesis Institute of Dental Sciences & Research
Ferozepur- Moga Road, Ferozepur.
APPLICATION FORM: HOSTEL ACCOMMODATION
PART – I
Personal Particulars and Accommodation Requirement
1. Name (IN BLOCK CAPITALS)
2. Pet Name (IN BLOCK
CAPITALS)
3. Date of Birth Date Month Year
4. Blood Group Identification Mark ____________________________
5. Roll No. University Roll No.
6. I Card No*. Outpass Card No*.
*(to be filled by Warden)
7. Address for correspondence ____________________________________________________________________________________
or Leave
____________________________________________________________________________________
___________________________________________________________________________________
8. Contact No. Telephone No. with Code ____________________________(Fax No. if any)_____________________________
Mobile No.(Father)__________________________(Mother)____________________________(Student)_______________________
E. Mail ID (Father)_________________________________________(Student)____________________________________________
9. Tick √ Room Category Required Double Sharing Single Special
10. Tick √ Additional facilities Required AC Curtains Mattresses
11. Tick √ Type of Meals Vegetarian Eggitarian Non-Vegetarian ( NA for Special Room)
12. Special Medical Attention ______________________________________________________________________________________
(Parents to indicate & Hand
over Duplicate Documents ____________________________________________________________________________________
(Certify nothing with held
If NA) ____________________________________________________________________________________
13. Special Talent/Hobby Reading ________________________________ Music ______________________________________
Singing ________________________________ Out door____________________________________
Dramatics ________________________________ Any other __________________________________
14. Games (Mention anyone) ____________________________________________________________________________________
(Indicate School, State or National Level)
15. Indoor Games (Mention anyone)
(Indicate School, State or National Level) _______________________________________________________
Signed
Photograph
Sr. No _____________
PART – II
Particular Parents
16. Father’s Name
(IN BLOCK CAPITALS)
Identification Mark ________________________________
Specimen Signature. __________________________________
17. Parent’s Profession ________________________________________________________________________
18. Mother’s Name (IN BLOCK
CAPITALS)
I
Identification Mark __________________________________
Specimen Signature. __________________________________
19. Other Blood Relative (Sister, Brother, Grand Parent)
1 2 3 4
Relationship: ______________Relationship: ______________Relationship: _______________Relationship: ____________
Signature : _______________Signature : ________________Signature : _________________Signature : ______________
Identification Mark(1) ____________________________Identification Mark(2)_____________________________
Identification Mark(3)____________________________ Identification Mark(4)_______________________________
Signed Photograph
3 copies
Signed
Photograph
3 copies
Colored
Photograph Signed by
Father
3 copies
Colored
Photograph Signed by
Father
3 copies
Colored
Photograph Signed by
Father
3 copies
Colored
Photograph Signed by
Father
3 copies
Sr. No.__________
APPLICATION FORM HOSTEL ACCOMMODATION
PART – III
Particulars Local Guardian
20.. Name (In BLOCK CAPITALS)
Specimen Signature ___________________________________
Identification Mark ____________________________________
Relationship _________________________________________
Contact Address:
________________________________________________________________________________________
______________________________________________________________________________________
________________________________________________________________________________________
Contact Number:
________________________________________________________________________________________
21. Details any other Relative permitted to meet
Specimen Signature ___________________________________
Identification Mark ___________________________________
Relationship _________________________________________
Contact No. _________________________________________
PART – IV
Undertaking by Student & Parents to abide by rules
Certified that my ward will abide by all rules, regulations & policy regarding hostel, messing and its routine, which have been
explained and fully understood by me and my ward. We accept all terms and conditions regarding, dress code, daily schedule messing,
charges, discipline activities out pass permission for all outings and any other activities. No visitor other than those authorized will be
permitted. Visitor will be permitted only during visiting hours only.
Signature of Ward
Signature of Father
Signed
Photographs by Father
3 copies
Signed
Photographs by Father
3 copies
Sr. no.
AFFIDAVIT ( PARENT OF STUDENT)
I, __________________________ Son/Wife of Sh._____________________________________
R/O____________________________________do hereby solemnly affirm and declare:-
1) That Mr./ Ms._______________________AIPMET No. _________________________ is my son/daughter
and he/she has taken provisional admission in B.D.S Course at Genesis Institute of Dental Sciences &
Research (Dental College & Hospital ), Ferozepur , Punjab. Batch 2015-20.
2) That I further declare that my son/daughter Mr./Ms____________________________bears a good moral
Character.
3) That I being the Father/Mother/ of Mr. /Ms_______________________________ undertake the entire
responsibility of his/her good behaviour and he/she will maintain proper discipline during his/her stay in
college.
4) That he/she will not participate in any Union activities, nor any strike.
5) That I have specifically been explained about the order of the Hon’ble Supreme Court of India dated 16-5-
2007 regarding curbing the menace of Ragging in Educational Institutions. I have also been explained that
on being found indulging in the incident of ragging, my ward can be expelled from the Institution
6) That I have personally read (in the language I read/ understand) & understood the provisions of Medical
Council of India Notification & as well as reproduced in the form of guidelines in the prospectus & fully
understood the contents, implications & agree & will abide by the policy guidelines laid there in. I shall
have no legal standii to contest these if my ward is affected due being found guilty.
7) That after admission if my son/daughter Mr. /Ms _________________________Migrates from this institute
or leaves this institute for any reason, I will be bound to pay full fee up to final year, as per fee structure
fixed at that time.
8) That I will pay the enhanced college fee and other dues to the authorities as and when notified from time to
time.
9) That I will pay all fee dues which includes Tuition, Hostel & Messing, Allied Services, Damages & other
dues as per schedule laid by the college & will be liable for fine/ disciplinary action deemed fit by Institute
management, which will be final.
10) That no additional money except mentioned in the prospectus/ notification has been paid by
me to the college authorities.
11) That the college authorities have explained to me the status of college regarding Govt. approval & University
affiliation and I am admitting my ward after thorough consideration & my full satisfaction.
12) That, all the charges regarding eligibility certificate, lab requirements, registration fees,
Examination fee, admission fee, or any other charges by the State Govt. or University will
be paid by me.
13) That in case of modification of the fee structure, I shall be liable to pay the modified fee or
difference thereafter as the case may be.
14) That my ward Mr/ Ms ____________________________________has not passed any other qualifying
examination from more than one Board/University/any other examining body.
15) That I will furnish a surety bond/bank guarantee for rest of fee & will be liable to pay the balance fee for the
whole course, even if my ward leave the Institute / course midway course within one month.
16) That I shall not claim adjustment of security deposit or any other surety, till my ward has
passed out & all other dues adjusted by college authorities.
17) That my ward Mr./Ms.------------- is not suffering from any chronic medical problem & I
have not concealed any information about behavior aberration from the college authorities.
18) That, I have carefully read and fully understood the law prohibiting ragging and the directions of
Hon’ble Supreme Court and the Central/State Government in this regard as well as the MCI Regulations
on Curbing the Menace of Ragging in Higher Educational Institutions, 2009.
19) I assure you that my son/ daughter/ ward will not indulge in act of ragging.
20) I hereby agree that if he/she found guilty of any aspect of ragging, he/she may be punished as per the
provisions of the MCI Regulations mentioned above and / or as per the law in force.
Signed this -------------------------day of---------------------month of---------------year at -------------------------------
Address: ______________________ Deponent
I further solemnly affirm and declare that the above statement is true to the best of my knowledge and belief and nothing
has been concealed therein and will adhere to all commitments made therein.
Dated: __________ Attested Deponent
Magistrate/Notary Public
AFFIDAVIT: (STUDENT)
I, __________________________________ AIPMET NO. -----------------Son/daughter of Sh.______________
R/O____________________________________do hereby solemnly affirm and declare:-
1) That I have taken provisional admission in B.D.S Course at Genesis Institute of Dental Sciences & Research(Dental
College & Hospital), Ferozepur, Punjab. Batch 2015-20.
2) That I bear a good moral character.
3) That I undertake to maintain good behaviour and I will maintain proper discipline during my stay in college.
4) That I will not participate in any Union activities, nor any strike.
5) That I have specifically been explained about the order of the Hon’ble Supreme Court of India dated 16-5-2007
regarding curbing the menace of Ragging in Educational Institutions. I have also been explained that on my being
found indulging in the incident of ragging I can be expelled from the Institution
6) That I have personally read (in the language I read/ understand) & understood the provisions of Medical Council
Of India, Notification & as well as reproduced in the form of guidelines in the prospectus & fully understood the
contents , implications & agree & will abide by the policy guidelines laid there in. I shall have no legal standii to
contest these if I am affected due being found guilty.
7) That if I migrate from this Institute or leave this Institute for any reason, I will be bound to pay full fee up to final
year as per fee structure fixed at that time.
8) That I will pay the enhanced college fee and other dues to the authorities as and when notified from time to time.
9) That I will pay all fee dues which includes Tuition, Hostel & Messing, Allied Services, Damages & other dues as per
schedule laid by the college & will be liable for fine/ disciplinary action deemed fit by Institute management, which
will be final.
10) That no additional money except mentioned in the prospectus/notification has been paid by me to the college
authorities.
11) That the college authorities have explained to me the status of college regarding Govt. approval & University
affiliation and I am seeking admission after thorough consideration & my full satisfaction.
12) That all the charges regarding eligibility certificate, lab requirements, registration fee, examination fee, admission
fee, or any other charges by the State Govt. or University will be paid by me.
13) That in case of modification of the fee structure, I shall be liable to pay the modified fee or difference thereafter as
the case may be.
14) That I have not passed any other qualifying examination from more than one Board/University/any other examining
body.
15) That I will furnish a surety bond/bank guarantee for rest of fee & will be liable to pay the balance fee for the whole
course, even if I leave the Institute / course midway course.
16) That I shall not claim adjustment of security deposit or any other surety, till I have passed out & all other dues
adjusted by college authorities.
17) That I am not suffering from any chronic medical problem & I have not concealed any information about behavior
aberration from the college authorities.
18) That I have been explained in the language, I understand & have fully understood my personal
responsibility of ragging at fresher stage & after I become senior.
19) I will be obliged to attend all official function & additional courses specified by the college
authorities & will pay all charges laid to all.
20) That, I have carefully read and fully understood the law prohibiting ragging and the direction of the Supreme Court
and the Central/State Government in this regard.
21) I have received a copy of the MCI Regulations on Curbing the Menace of Ragging in higher Educational
Institutions, 2009.
22) I hereby undertake that-
I will not indulge in any behavior or act that may come under the definition of ragging,
I will not participate in or abet or propagate ragging in any form,
I will not hurt anyone physically or psychologically or cause any other harm.
23) I hereby agree that if found guilty of any aspect of ragging, I may be punished as per the provisions of the MCI
Regulations mentioned above and / or as per the law in force.
Signed this -------------------------day of---------------------month of---------------year at -----------------------------
Address: ______________________ Deponent
I further solemnly affirm and declare that the above statement is true to the best of my knowledge and belief and nothing
has been concealed therein and will adhere to all commitments made therein.
Dated: __________ Attested Deponent
Magistrate/Notary Public
AFFIDAVIT AS REQUIRED BY
MEDICAL COUNCIL OF INDIA
UNDERTAKING BY THE CANDIDATE/ STUDENT
I, --------------------------------------------------------------------------------------------------
S/o. D/o. of Mr./Mrs./Ms.----------------------------------------------------------------- have carefully
read and fully understood the law prohibiting ragging and the direction of the Hon’ble Supreme
Court and the Central/State Government in this regard.
1. I have received a copy of the MCI Regulations on Curbing the Menace of Ragging in higher
Educational Institutions, 2009.
2. I hereby undertake that-
I will not indulge in any behavior or act that may come under the definition of ragging.
I will not participate in or propagate ragging in any form.
I will not hurt anyone physically or psychologically or cause any other harm.
I will not abet any act which falls under the definition of ragging.
3. I hereby agree that if found guilty of any aspect of ragging, I may be punished as per the
provisions of the MCI Regulations mentioned above and / or as per the law in force.
Signed this -------------------------day of---------------------month of---------------year
Signature
Name:
(1) Witness:
(2) Witness:
Dated _________________ Deponent
I further solemnly affirm & declare that the above statement is true to the best of my
knowledge & belief & nothing has been concealed therein & will adhere to all commitments made
therein. I assure that the decision by the institute management will be final & binding.
Dated _________________ Deponent
Attested
Magistrate/Notary Public
AFFIDAVIT AS REQUIRED BY
MEDICAL COUNCIL OF INDIA
UNDERTAKING BY THE PARENTS/GUARDIAN
1. I, -------------------------------------------------- Roll No. (AIPMET NO.-------------------------
F/o. M/o. G/o.----------------------------------------------------------------- have carefully read and
fully understood the law prohibiting ragging and the directions of Hon’ble Supreme Court and the
Central/State Government in this regard as well as the MCI Regulations on Curbing the Menace of
Ragging in Higher Educational Institutions, 2009 (handout given separately)
1. I assure you that my son/ daughter/ ward will not indulge in act of ragging.
2. I hereby agree that if he/she found guilty of any aspect of ragging, abetting such act which falls
under the definition of ragging he/she may be punished as per the provisions of the MCI
Regulations mentioned above and / or as per the law in force.
Signed this -------------------------day of---------------------month of---------------year
Signature
Name:
I. Witness:
II. Witness:
Dated _________________ Deponent
I further solemnly affirm & declare that the above statement is true to the best of my
knowledge & belief & nothing has been concealed therein & will adhere to all commitments made
therein. I assure that the decision by the institute management will be final & binding.
Dated _________________ Deponent
Attested
Magistrate/Notary Public
GENESIS INSTITUTE OF DENTAL SCIENCES & RESEARCH, FEROZEPUR.
Form for Leave Application
Roll No. :________________ Class: __________________
Name of the Student : _______________________________________________
Father's name : __________________ Mother's Name :________________
Home Address : ________________________________________________
________________________________________________
________________________________________________
Period of Leave required: _________________to ______________________
(Both days inclusive).
Reason for Leave. _______________________________________________
I certify that the above particulars are correct. My parents are in the knowledge of and have
given their consent for the leave applied. I and my parents shall be fully responsible for my
wellbeing, travel to and fro and safe return to the institute after expiry of the leave specified above. In
case I do not return back on the expiry of this leave my parents may be informed accordingly. I and
my parents shall also be responsible for shortage of attendance (if any) on account of this leave.
Contact Mobil No. of the student.________________
Contact Mobil Nos. of the parents.________________
Land Line No. of the parents._________________
Date:______________ Full Signature __________________
__________________________________
Signature of the Hostel Superintendent.
(With date)
Leave Sanctioned.
Director Administration
Date________________
