Roll No. Form No.

(To be filled by the office)

Sanjay Gandhi Postgraduate Institute of Medical Sciences

Raebareli Road, Lucknow

U.P. Post Graduate Medical Entrance Examination-2002

for Admission to Post-Graduate Courses (M.D/M.S./DIPLOMA/M.D.S)

APPLICATION FORM

(incomplete application will not be entertained)

  1. Name : ______
  2. Father's Name : ______
  3. Nationality : ______
  4. Place of Birth : ______
  5. Date of Birth : ______

(attach attested Photocopy)

  1. Whether S.C./S.T./O.B.C. (if yes, attach certificate from competent authority):

______

  1. Full mailing address (with PIN Code ): ______

______

  1. Permanent address (with PIN Code) :______

______

  1. Present Job/Service (if any) : ______

10. (A) Examination passed (attach attested photocopy of mark-sheets of all the professional examinations)

Class / Institution / Marks / Month and Year of Passing
Maximum / Obtained / Aggregate %
M.B.B.S./B.D.S. Ist Professional
M.B.B.S./B.D.S. 2nd Professional
M.B.B.S./B.D.S. Final Part-I/ III Professional
M.B.B.S./B.D.S. Final Professional
Average percentage of aggregate


10. (B) Examination passed (attach attested photocopy)

Degree / Institutions / Subjects / Year of Admission / Year of Passing
M.D./M.S. Diploma /M.D.S.

11.  Date of Completion of Compulsory Rotatory Internship (attach attested photocopy) :______

12.  Registration (attach attested photocopy / Name of Medical /Dental Council / Registration No.

13.  Mention year-wise account of time gap between completion of internship till submission of application for UPPGMEE-2002

From / To / Details
Course / Job / Assignment

DECLARATION BY THE APPLICANT

(a)  I ...... S/o., D/o...... resident of (Permanent address) ......

......

hereby declare that I am not studying in postgraduate course in any State Medical Colleges of U.P. and K. G. Medical College, Lucknow on the basis of U.P.P. G.M.E.E. or A.I.E.E

(b)  I hereby declare that the above application has filled in my own hand-writing and the information given by me in the application form is correct and nothing has been concealed. In case, at any stage, it is found that information furnished by me is false, I shall have no claim to admission and if already admitted, my admission may be cancelled.

(c)  I further declare that, I shall abide by the rules governing the course as laid down by the Govt. of U.P. and the Institution providing the course.

(d)  I am presently not employed/employed in......

I know that in case of any dispute the decision of the Director-Coordinator, U.P.P.G.M.E-2002/ Director General, Medical Education and Training, U.P. shall be final and binding on me.

(f)  I am domicile of U.P. and was admitted in ...... (College)...... (city) through 15% All India quota in the year ......

(g) That I have not filed any petition in any court of law related to my admission through previous U.P. P.G.M.E.E. Examination.

I have filed a petition no...... in...... court and I will withdraw my petition if a course is allotted to me on a basis of U.P. P.G.M.E.E.-2002.

Date Signature of Candidate

FORWARDING NOTE BY THE PRINCIPAL

(Only for those who are pursuing internship)

(a)  Dr ...... has passed the M.B.B.S./B.D.S. Examination from this Institution.

(b)  The candidate is expected to complete Internship by

Signature with Seal

FORWARDING NOTE TO BE SIGNED BY THE COMPETENT AUTHORITY OF THE ORGANISATION IN WHICH THE CANDIDATE IS EMPLOYED (IF APPLICABLE)

I certify that this application is being made with my consent and permission and that he/she will be immediately relieved, if selected for the course.

Signature with Official Seal


For Office Use Only Form No.

Sl. No. : ______

Roll No. ______

U.P. POST GRADAUTE MEDICAL ENTRANCE EXAMIANTION-2002

COMPUTER RECORD SHEET

(A)  Please read the instructions carefully given in the brochure (B) write all the particulars in capital LETTERS clearly and legibly

(C)  Write your name in capital LETTERS as given in the records of the secondary education Board/University

(D)  Entries filled in this sheet are firm and final (E) Please do not fold.

FULL NAME
FATHER'S NAME
  1. FULL MAILING ADDRESS WITH PIN CODE

STATE / PIN-CODE

4. SEX (CODE 1-MALE, 2 -FEMALE) 5. CATEGORY (

DATE MONTH YEAR

  1. DATE OF BIRTH
  1. AVERAGE % OF MARKS OBTAINED

ALL PROFESSIONAL EXAMINATIONS .

DATE MONTH YEAR

  1. DATE OF COMPLETION OF INTERNSHIP
  1. INSTITUION FROM WHICH YOU HAVE

PASSED THE MBBS/BDS DEGREE COURSE

(CODE 1-FOR JH, 2-FOR KNP, 3-FOR LKO. 4-FOR MRT, 5-FOR AG, 6-FOR ALD., 7-FOR GR, 8-FOR MEDICAL COLLEGES OF OTHER STATES)

  1. WHETHER IN SERVICE

(INCLUDING PG/NON PG Jr. RESIDENCE/HOUSE JOB etc.) (CODE 1-FOR YES, 2- FOR NO)

DATE

(JH-Jhansi: KNP-Kanpur: LKO. -Lucknow: MRT-Meerut: AG-Agra: ALD-Allahabad: GR-Gorakhpur)

Use Black Ball Point Pen only

Sanjay Gandhi Postgraduate Institute of Medical Sciences

Raebareli Road, Lucknow

U.P. Post Graduate Medical Entrance Examination-2002

U.P.P.G.M.E.E. - 2002

Admit Card

Important

The candidate is required to fill the Admit Card neatly & legibly except Roll No.

(To be attached with application form)

Roll No. APPROVED/PROVISIONAL

Specialty ______

Name______

ADDRESS______

(Postal) ______

______

______

NAME OF EXAM CENTRE

Signature of the Candidate______

Programme of Examination

Day /

Date

/

Time

/

Venue

1.  WRITTEN TEST
2.  COUNSELLING

Verified and issued Director-Coordinator

(ER/Office Incharge)

·  Reasons for being provisional-Please see attached leaf