Rs.

500/- For general (including prospectus)

Price : Session : January, 2008 Form No.___________
Rs. 400/- For SC/ST (including prospectus)
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH 160012

Application form for______________________________Course ROLL NO.

Speciality Applied for__________________________________
Application form duly completed should
reach the office of the REGISTRAR
by 29-10-2007
(TO BE ASSIGNED BY OFFICE)

IMPORTANT NOTE : BEFORE FILLING UP THIS APPLICATION FORM PLEASE READ THE
ADMISSION NOTICE AND THE PROSPECTUS SUPPLIED WITH THIS FORM CAREFULLY

REGISTRAR
Postgraduate Institute of Medical
Education & Research, Chandigarh - 160 012
Sir, Please paste here a
passport size coloured
I submit my application for admission to the course ticked (3) below photograph attested by the
Gazetted Officer
MD/MS DM/M.Ch. MHA House Job (Dentistry)

Subject:______________________________________________________ FOR OFFICE USE ONLY

a) For Sponsored & foreign MD/MS candidates, mention one subject
for which they have been sponsored.
b) For DM/M.Ch._________________________________________ Dy. No._______________
(The candidates are required to submit separate application for each
subject they want to apply for)
Date_________________
c) I am an applicant under the category ticked (3) below :-

1. General (To be filled only by the candidates

who download the form website)
2. Sch. Caste
Bank Draft/Postal order No......................
3. Sch. Tribe
Date of issue.............................................
4. Rural Area Service
Name of the issuing Bank........................
5. Orthopaedic Physically Handicapped
(Column No. 2, 3, 4, 5 are not applicable to DM/M.Ch. courses) Amount Rs................................
6. Sponsored / Deputed______________________________
(Also mention subject)
Yours faithfully,
7. Freign National__________________________________
(Also mentin subject)
(Signature of the Candidate)
Note : The change of category at any stage will not be permitted
(________________________)
Place__________________________ Name in Block Letters)

Dated_________________________

1
The application form and the acknowledgement card must be completed in the candidate's own handwriting using ball point
pen.
An application which is incomplete or wrongly filled in, will be rejected.
1. (a) Name in full ( In block letters) : ___________________________________
(In English)
(b) In Hindi (Devnagri Script) : ___________________________________
2. Date of birth (as recorded in matriculation or its : ___________________________________
equivalent certificate according to Christian Era)
3. (i) (a) Father's Name ( In English) : ___________________________________
(b) In Hindi (Devnagri script) : ___________________________________
(ii) (a) Mother's Name (In English) : ___________________________________
(b) In Hindi (Devnagri Script) : ___________________________________
4. Father's occupation and annual income : ___________________________________
5. (a) Do you belong to Scheduled Caste/Tribe : ___________________________________
(b) If yes, state your caste and religion : ___________________________________
(attach proof)
6. Sex : : ___________________________________
7. Married or unmarried : ___________________________________
(if married, wife/husband name & occupation) ___________________________________
8. Nationality : ___________________________________
9. State/Union Territory to which you belong : ___________________________________
10. Address in block letters
(a) Where interview/selection letter etc. should be sent: ___________________________________

(b) Permanent Home Address : ____________________________________

(c) Telegraph address (if any) : ____________________________________

(d) Telephone No. (Mobile Phone) STD Code_______ : No. _________________________________

(e) e-mail address (if any) : ____________________________________

11. Permanent Medical Registration number and the state ____________________________________
in which registered.
12. Are you doing/have done MD/MS ? : ____________________________________
12A. Are you employed If yes, give the following details : ____________________________________
(a) Date of joining : ____________________________________
(b) Nature of job : ____________________________________
(c) Name of the Institution/Hospital Govt./
Semi Govt./ Pvt. : ____________________________________
(d) Designation : ____________________________________
(e) Pay Scale : ____________________________________
(f) Name of employer : ____________________________________
Note : If you are doing /have done MD/MS, you are not eligible
for applying for MD/MS course. Please refer to the point
‘d’of General Information of the prospectus.
2
13. Details of MBBS/BDS/MD/MS Examination
(a) A failure in the examination, compartment or re-appear in one or more subjects will constitute an
attempt.

(b) The attempts made at passing the examinations should be mentioned as "FIRST" i.e. No failure/
No compartment/No re-appear). " SECOND" (i.e. one failure/compartment/re-appear etc.) and not as "ONE"
or TWO” etc.)

Examiantion Passed Name of University/ Month & Year in Attempts at which Proof at encl. No.
Institute which passed passed

First Professional

Second Professional

Third Professional

Final Professional

Percentage of marks obtained in the final_____________________________________MBBS/BDS examination.

13. (b) Details of internship or compulsory rotatory house job.
Name of Hospital From To Yr. Month Days Date of Completion Proof at Encl.No.

13. (C) Postgraduate examination passed

Name of examination Name of the college A. Name of whether the Whether college/ Attempts Proof at
passed and from which the Univerity / MD/MS is Institution is at which Encl.
the subject candidate passed Institution recognised by recognised by passed No.
MD/MS B.Month & MCI, If yes MCI if yes
Year in enclosed enclosed
which passed proof proof

3
14 Have you worked / are working/or doing private practice in rural area for a period of two years or more ? If
so, give details :

Name of Hospital Capacity in which Pay scale Period Proof at

Place Worked From To Yr Month Days encl. No.

15. Give names and complete addresses : 1. _______________________________________

of two referees not related to you
_______________________________________

_______________________________________

2. _______________________________________

_______________________________________

_______________________________________

16. Have you any contact persons/guardian in _______________________________________

Chandigarh. If so, mention his/her address
Telephone No., if any. _______________________________________

_______________________________________

17. Are you being sponsored/deputed by your

employer? If sponsored, the application _______________________________________
must be accompanied with sponsorhsip,
deputation certificate in the form printed
at page 7.

Date____________________ (______________________________________)
Signature of the applicant
Place___________________

NOTE : PLEASE DO NOT LEAVE ANY COLUMN UNFILLED / BLANK

4
 ATTEMPT CERTIFICATES
The application must accompany the undermentioned certificates duly signed by the Principal or Medical College/Institute
from where the candidates has passed his/her MBBS/MD/MS/BDS Examination.

NB : 1. The failure of candidate in any professional MBBS/BDS examination or his/her having been placed in
compartment or re-appear in one or more subjects shall constitute as an attempt.
2. The entries under the headng “column” at which passed should be indicated as “FIRST” (i.e. no failure/
Compartment/re-appear), “second” (i.e. one failure/compartment/re-appear) etc. and not as “one”, “two” etc.
3. No other certificate than the one conforming to the under-mentioned format will be accepted.

ATTEMPT CERTIFICATE - I
Certified that Dr._______________________________________________________________________
son/daughter of Sh.____________________________________________________________________________
has passed professional examination of the MBBS/BDS course as per detail given below :--
Examination passed Attempted at which passed
1. First professional _____________________________________
2. Second professional _____________________________________
3. Third professional _____________________________________
4. Final professional _____________________________________
It is also certified that MBBS/BDS degree of this medical/dental college is recognized by the Medical Council/
Dental Council of India.
It is certified that _________________________________________commenced his/her rotatory compulsory
internship training on __________________ and is due to complete the same on ________________
OR
It is certified that ______________________________________has completed his/her compulsory rotatory
internship on __________________________

Session :_________________________ Signature___________________________

Designation __________________________
(Official Seal)

ATTEMPT CERTIFICATE - II
Certified that Dr.________________________________son/daughter of Sh._________________________
has passed the MD/MS examination from the Institute/University in the subject of ____________________________
in the_________________attempt(s)
It is certified that the abovesaid MD/MS degree of the institute/University is recognised by Medical Council of
India.
It is further certified that the degree of M.D./M.S. of College/Institution in the subject of_______________
awarded to him/her is recognised by the Medical Council of India as per their letter No.__________________.
A photocopy of the same is enclosed.

Station ___________________ Signature_________________

Dated____________________ Designation_______________
Official Seal______________

Note : 1. Deletion/alteration of any word in the above certifcate will lead to rejection of the application summarily and
no intimation will be sent to the candidate.
2. In case a photocopy of the letter from the Medical Council of the India Post Graduate Degree College/
Institution is not enclosed, the application will not be considered.

5
 DECLARATION BY CANDIDATE
I hereby declare that the application has been filled in my own handwriting and all statements made in it are true,
complete, and correct to the best of my knowledge and belief and nothing has been concealed. In the event of any statement
being found false or incorrect or any ineligibility being detected before or after the selection, action such as removal of my
name from the rolls and/or any other action as may be considered necessary can be taken against me.

2. I also declare that I have carefully read the contents of the Prospectus in respect of the course applied for by me and
undertake to abide by the provision contained therein.
3. I further declare that I fulfil all the eligibility conditions regarding educational qualification, experience etc. pre-
scribed by the Institutte for admission to the course applied for by me.

4. If selected :
a) I agree to work on whole time basis :
b) I shall not engage myself in private practice or part time job during the period.
c) I shall not draw any pay, fellowship or any kind of monetary assistance from any other sources, if I am
allowed emoluments by the Institute.

Place ___________________ (____________________________________)

Date____________________ Signature of the applicant

DECLARATION BY THE FATHER/GUARDIAN OF THE APPLICANT

I hereby declare that I shall be responsible for timely payment of all dues payable to the Postgraduate institute of
medical Education & Research, Chandigarh in respect of my son/daughter/ward (name_____________________________
_________________________) during the period of his/her stay at the Institute and there after until the dues are
cleared.

Address_______________________________ ( )
Signature
_________________________________________ Relationship to the applicant

ENDORSEMENT BY THE EMPLOYER, IF THE APPLICANT IS IN SERVICE

No................................... Date.....................................

Forwarded to the REGISTRAR, Postgraduate Institute of Medical Education & Research, Chandigarh for
consideration. The undersigned has no objection to the applicant of Dr.__________________________________being
considered by the Institute for the course applied for by him/her and if selected, he/she will be relieved within, the
prescribed time limit. The applicant is “sponspored/deputed or not sponsored/deputed by us and the sponsorship/
deputation-certificate is enclosed.

Address ____________________________________ Signature of the employer

___________________________________________ with official seal

*Strike out whichever is not applicable

6
 RURAL AREA SERVICE CERTIFICATE
Certified that Dr.___________________________________________________________ son/daugther of
Shri__________________________________Registration No.___________________has served or carried on private practice
in the following place(s) during the period indicated against each :

Place Period
From To

Certificate that the above mentioned place comprises a village or a Primary Health Centre of a town with population
of less than 5000 and without a municipal area.

Date___________________ Signature of the Distt. Magistrate

Station_________________ With Seal

SPONSORSHIP CERTIFICATE
(Applicable only in case of candidates who are sponsored/deputed)
Note : Sponsorship from Private Hospital/Institute/Nursing homes, etc. is not accepted.

Certified that Dr.__________________________________________________________son/daughter of

Shri_________________________________is a permanent / regular employee of the Govt. Deptt./Medical College
since_________________(Date) and has THREE YEARS of Regular/Permanent Service.

Please tick (3) the type of Institution/department sponsoring/deputing the candidate viz.
1. 1. Central Govt. 2. State Govt. 3. Autonomous Body of Central Govt. 4. Autonomous Body of State Govt. 5. Public
Undertaking 6. Medical College/Hospital affiliated to a University and recognised by Medical Council of India.
2. Certified that if selected for the course applied for by the applicant he/she will be suitably employed by us after the
completion of his/her training course to work for atleast five years in the speciality in which the training is received
by him/her at PGI, Chandigarh
3. Certified that no financial implication in the form of emoluments/stipend etc. will devolve upon PGI, Chandigarh
during the entire period of applicant’s course. Such payment will be the responsibility of sponsoring/deputing
authority.

Date____________________ Signature of the sponsoring/

Station__________________ deputing authority with seal

NB.1 Deputation/Sponsorship of candidates holding tenure appointments (like House Job or Junior or Senior or Senior Residency),
adhoc or contract or honorary or appointment against a leave vacancy shall not be accepted.
2. The sponsoring/deputing institution should not nominate more than one candidate for a speciality./super speciality.
3. The candidate must indicate the subject of their choice in the application clearly as page 1.
Sponsoring/deputation of candidates will be accepted only from the following :
(a) Central Govt. Departments/Institution
(b) State Govt. Departments/Institution
(c) Autonomous bodies of the Central or State Govt.
(d) Public Sector Undertakings
(e) Medical Colleges affiliated to a University and recognized by the Medical Council/Dental Council of India.

In case of candidates deputed/sponsored by Medical Colleges affiliated to a University and recognized by the Medical
Council of India, the deputation/sponsorship certificate signed by the Principal of the Medical College concerned only shall be
accepted.
Note : The three photographs to be pasted on this form at the place indicated must be identical. The photograph
should be signed by the candidate in ink on the front.
7
Essential documents which must accompany the applications :

Documents Enclosure No.

1. Attested copy of Matriculation/Higher Secondary Certificate

showing date of birth. ____________________________
2. Attested copy of certificate of passing MBBS/BDS examination ____________________________
3. Attested copy of certificate of passing MD/MS examination ____________________________
4. Internship completion certificate ____________________________
5. Attempt certificate I and II in the forms appended to the ____________________________
application form. No other certificate is entertained.
6. Attested copy of certificate of the character and conduct from ____________________________
the Institution last attended.
7. Attested copy of certificate of permanent Registration with ____________________________
central / State Medical Registration Council/Dental Council of India
8 Attested copy of Caste Certificate in Hindi/English Script ____________________________
9. Sponsorship/deputation certificate in the prescribed form, if applicable. ____________________________

10. Acknowledgement card with postage stamp of Rs. 5/- affixed thereon. ___________________________
11. Three self addressed envelopes of size 10 x 23 cms. Rs. 5/- postage ___________________________
stamp on each envelop for use by this office for sending interview
letters, etc.
12. Rural Area Certificate attested by Distt. Magistrate ____________________________

13. Orthopaedically handicape certificate (if applicable) _____________________________

IMPORTANT NOTE

In case any candidate is found to have supplied

false information or certificate etc. or is found to
have concealed or withheld some information in his/
her application form, He/She shall be debarred from
admission.
Any other action that may be considered appropri-
ate by the Director of the Institute may also be
taken against Him/Her which may include criminal
prosecution.

Dated_____________________________
Place _____________________________ Signature of the Candidate

No. of Enclosures :__________

8
 POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH
APPLICATION FORM FOR THE ADMISSION IN MD/MS,DM/M.Ch., MHA House Job (Dentistry) COURSES

SESSION : JANUARY, 2008

(Form for the Computer)

INSTRUCTIONS
1. Please read the Information given in the prospectus carefully Serial No.
before filling up this Application Form.
Roll No.
2. This application form should reach on or before 29-10-2007
(To be filled in by the Office)
3. Use only BLUE/BLACK ink to fill in BLOCK/CAPITAL LETTERS.

CANDIDATE’S NAME

FATHER’S NAME

MOTHER’S NAME

ADDRESS FOR COMMUNICATION (Please do not repeat your name and father’s name)

City Pin Code

DATE OF BIRTH NATIONALITY SEX

1=Indian 1=Male
2=Foreign 2=Female
Day Month Year

CATEGORY COURSE For DM or Mch Course, mention

A. General Super Specality Code as given overleaf
B. Scheduled Caste 1-MD/MS
C. Rural Area Services 2-DM/M.Ch
D. Sponsored/Deputed 3-MDS
E. Scheduled Tribes
4-House Job (Oral Health Sciences)
F. Foreign/National
G. Orthopaedic Physically Handicapped
For Category D, F&G mention name of the subject

%age Marks in MBBS/BDS MBBS/BDS MD/MS Date of Completion of Internship Employed

. % 1=yes
2=No
(Enter Max. attempts taken in any Day Month Year
of MBBS/BDS, MD/MS exam.)

DECLARATION
I have carefully read the Instructions given in the prospectus. I hereby solemnly and sincerely affirm that the Statement
made and information furnished by me with application form are true and correct. If, however, it is found that any
information furnished herein is fraudulent, incorrect or untrue in material particulars, I realise that I am liable to
criminal prosecution and my selection and admission to the course is liable to be cancelled.

Date Signature of Candidate

List of Super Specialities for DM/M.Ch Courses

Code Super Speciality Code Super Speciality

01 Cardiology 08 Pulmonary & Critical Care Medicine
02 Clinical Pharmacology 09 Cardiovascular & Thoracic Surgery
03 Endocrinology 10 Neurosurgery
04 Gastroenterology 11 Paediatric Surgery
05 Nephrology 12 Plastic Surgery
06 Neurology 13 Urology
07 Neonatology
 POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH, CHANDIGARH 160012

SELECTION OF CANDIDATE FOR MD/MS, DM/M, CH., MHA, HOUSE JOB (DENTISTRY) COURSES
SESSION :JANUARY, 2008
Category_____________________ Candidate's Attendance Sheet

1. Roll No________________________________ Please paste here a

(to be assigned by Office) passport size
coloured photograph
2. Examination Centre : Chandigarh attested by the
Gazetted Officer
3. Specimen signature of the candidate__________________________

.......................................................................................................................................................
Nothing to be written below this line by candidate
.......................................................................................................................................................
ATTENDANCE SHEET
.......................................................................................................................................................
Date and Time Signature of candidates Signature of Invigilator
(to be signed in Examination Hall)
.......................................................................................................................................................

_________________ ________________________________ __________________

_________________ ________________________________ __________________

_________________ ________________________________ __________________

POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION & RESEARCH,

CHANDIGARH 160012

SELECTION OF CANDIDATE FOR MD/MS, DM/M, CH., MHA, HOUSE JOB (DENTISTRY) COURSES

Category_______________________ ADMIT CARD SESSION : JANUARY, 2008

1. Roll No.___________________________
(to be assigned by Office) Please paste here a
passport size
2. Examination Centre : Chandigarh coloured photograph
attested by the
3. Specimen signature of the candidate___________________________ Gazetted Officer

Please admit Dr._______________________________________________whose photograph along

with the specimen signature are affixed thereon to the selection test for MD/MS, DM/M.Ch.,MHA.,
House Job (Dentistry) mentioned above.

REGISTRAR
Postgraduate Institute of Medical
Education & Research, Chandigarh.