M.Sc. Medical Imaging Technology(Radiography) Course

Form No. ______

APPLICATION FORM

M.Sc. Medical Imaging Technology(Radiography) Course

Affix one recentUNIVERSITY COLLEGE OF MEDICAL SCIENCES

Photograph here dulyG.T.B. HOSPITAL, DELHI- 110095

attested on the front(SESSION : 2017-18)

side by a Gazetted

Officer/Principal of a

Recognized College/

Instt.

(for office use)

Please read instructions in the Prospectus carefully before you start to fill up the application form in your hand-writing.

1. Name of the Candidate (In BLOCK letter): ………………………………………………………………………………………………
2. Date of Birth :Day Month Year
3. Gender (Tick) :MaleFemale Others
4. Marital Status :MarriedUnmarried
5. Nationality: ……………………………………
6. Email address……………………………………………………………………………………………………………………………….
7. Mobile No. of the Candidate …………………………….………. Land line No. ……….…………………………………
8. Do you belong to General Category?YesNo
9. Do you belong to Scheduled Caste?YesNo (if yes, attach copy)
10. Do you belong to Scheduled Tribe?YesNo (if yes, attach copy)
11. Do you belong to OBC?YesNo (if yes, attach copy)
12. Do you belong to Person with disability (PWD)?YesNo (if yes, attach copy)
13. In-service CandidateYesNo (if yes, attach Proof)

Aggregate percentage of marks obtained in the qualifying exam. : ……………………… % (Result declared/ yet to be declared)

1. (a)Father’s or Guardian’s Name (In Block Letters): …………………………….…… Occupation ……….….………………….

Email address …………………………………………………… Mobile address ……………………….……………………..

(b)Mother’s Name (In Block Letters): ……………..……………………………………… Occupation …………..……….………….

Email address …………………………………………………… Mobile address ………………………………………………..

(c) Relationship (in case of Guardian) : …………………………………………………………………………………………….. (d) Annual Income (Rs.): ………………………………………………………………………………………………………………….. (e) His/her permanent address & Telephone No./Mobile No. (if any ) : ………………………………………...... …………………………………………………………………………………………………………………………………………………….

15.Details of Examinations Passed or appearing for :

16.University Enrolment No. : ……………………..

(Issued earlier by University of Delhi, incase the candidate has earlier passed any course from the University).

N.B.(i) In case of 10+2+3 system, the, Board/College/University and Roll No. must be mentioned.

(ii) If there is a break in the studies, it should be clearly mentioned, giving reason(s) for the interruption of the studies in

the remarks column or the space below.

(iii) Attach attested true copy of the mark sheet.

17. Address for correspondence(in full) including PIN code to which reply regarding this application may be sent (with

Telephone No.) if any
………………………………………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………………………………………….

DECLARATION BY THE CANDIDATE

I ______hereby declare that the application form has been filled in my own handwriting and that the information given by me in the above application form is correct. I further declare that I have read the rules as given in the Prospectus. I shall abide by the rules and regulations of the College and University of Delhi.

Place

Date Signature of the applicant

Name:______

DECLARATION BY THE PARENT OF THE CANDIDATE OR THE GUARDIAN OF THE CANDIDATE IN CASE

NEITHER OF THE PARENTS IS ALIVE

I ______hereby solemnly affirm and declare that the information furnished by the candidate is correct and nothing has been concealed. In the event that any false information has been furnished or that there has been suppression of any factual information in the application form, or comes to notice of the Institute authorities at any time during the course, he/she would be liable to be terminated besides other action by the Institute as may be deemed fit.

I further declare that I hold myself responsible for the timely payment of all dues, i.e. tuition fee, fines and other charges payable to the University College of Medical Sciences in respect of my son/ daughter/ ward during the period of his/ her studies at the College and thereafter until the accounts are cleared.

Address :

Signature of the Parent/ Guardian

Name:______

Date :

DECLARATION BY THE SCHEDULED CASTE/TRIBE/OBC/PWD APPLICANT ONLY

I hereby declare that I belong to a Scheduled Caste/ Tribe/ OBC/ PWD category and that I desire admission to the Institution under the special category for such candidate and I enclose herewith a Certificate from the prescribed authority as proof of the same.

Enclosures to be listed as per instructions in the Prospectus:

1. ……………………………………………………………………………………………………………………………………………………………………………..
2. ……………………………………………………………………………………………………………………………………………………………………………..
3. ……………………………………………………………………………………………………………………………………………………………………………..
4. ……………………………………………………………………………………………………………………………………………………………………………..
5. ……………………………………………………………………………………………………………………………………………………………………………..
6. ……………………………………………………………………………………………………………………………………………………………………………..
7. ……………………………………………………………………………………………………………………………………………………………………………..

CERTIFICATE FROM THE PRINCIPAL OF THE COLLEGE LAST ATTENDED

1. Certified that Mr./Ms. ………….……………………………….…………………………………………………………………………………
   S/o/D/o. …………………………………….…………………………………………………………………………………………………………….
   has studied in (Name of the Course) …………………………..………………………………………………………………… at
   (Name and Address of the School/College) ……………………………….……………………………………………………………
   …………………………………………………………………………………………………………………………….……………………………………
   from (mm/yy) ..………………..………….to (mm/yy) ……………..…………… (…………………………years).

2.Certified that Mr./Ms. ………………………..……………………………………………………. has studied in this
School/College a regular student.

3.He/ She has appeared/passed ……………………………………….……………….…….……… examination under 10+2+3

system in (mm/yy) …………………………………………………………….………………………….…………….. conducted by the

………………………………………….....……………………………………………………………… (Name of the Board/University).

4.He/ She bears a good moral character.

5.This College is recognized by ………………………………………………………………..…………. (Name of the University).

6.Date of Birth as per the Secondary School Certificate: …………………………………….………………………………………

Date………………………Signature of the Principal

and seal of the College.

Form No. ______

ATTENDANCE SHEET

Admission to M.Sc. Medical Imaging Technology (Radiography) Course

Saturday, 10th June, 2017Entrance Exam.

UNIVERSITY COLLEGE OF MEDICAL SCIENCES, DELHI-110 095.

(To be attached with the application form after affixing the photograph)

Reg. No. ______

1. Name (in BLOCK letters) :…………………………………………………………………………………………………………..
2. Father’s Name : …..……………………………………………………………………………………………………………………

Affix one recent

Photograph here duly

attested on the front

side by a Gazetted

Officer/Principal of a

Recognized School/

College/ Institution.

______

(Signature of the Candidate)

Do not fill/or Sign below this line while submitting the application.

------

For use during examination

(For office use only)

______

Signature of the candidate Signature of the Invigilator

at the time of examination (In case the candidate is absent

Invigilator may please write ABSENT

Date ……………………………… and put his signature.

Form No. ______

Admit Card

ENTRANCE EXAMINATION - M.Sc. Medical Imaging Technology(RADIOGRAPHY) Course2016-17

Saturday, 10th June, 2017 at11.00 A.M. to 12.30 P.M.

To be completed by the candidate

Affix one recent

Photograph here duly

attested on the front Full signature of the candidate

side by a Gazetted(Signature with office stamp of

officer/ Principal of a the Gazetted officer attesting the

RecognizedCollege/ Entrance Test- Date signature of the candidate)

Instt. 10th June, 2017 For office use only

Centre ROLL NO.

College Block,

UCMS &.G.T.B. Hospital,

Dilshad Garden Delhi-95.

PLEASE READ THE FOLLOWING INSTRUCTIONS CAREFULLY.

1. You must present this admit card at Examination Centre for securing entry to the Examination Hall.
2. You must present yourself at the Examination Centre on 10th June, 2017by10.30 a.m.
3. You must read carefully the instructions printed overleaf.
4. In future correspondence, you must quote your Roll No.

IN CASE, YOU ARE FOUND ELIGIBLEFOR ADMISSION, YOU HAVE TO FULFIL THE FOLLOWING CONDITIONS:

(i)Submission of two recent passport size photographs.

(ii)Submission of attested true copy of the Matriculation/Secondary School Exam. Certificate issue by the University/ board showing your date of birth.

(iii)Submission of certificate of good conduct from Principal/Head of the Institution last attended.

(iv)Submission of attested true copy/ photocopy of certificate from the prescribed authority stating that you belong to a Scheduled Caste/ Tribe/ OBC/ PWD community. (In case, you belong to a Scheduled Caste/ Tribe/ OBC/ PWD and you have applied for admission against the reserved quota.

(v)Submission of documentary evidence of your having passed qualifying examination with the required percentage of marks and subjects latest by 10th June 2017 falling which your performance at the Entrance Examination shall not be considered.

To be filled by the candidate

Name: ______

Father Name: ______

Address: ______

______

Tel.: ______

State______Pin Code______Section Officer (Acad.)

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FOR OFFICE USE ONLY Form No.______

UNIVERSITY COLLEGE OF MEDICAL SCIENCES

G.T.B. HOSPITAL, DELHI-110 095.

Received an application form from Mr./Ms. …………………………………………….….………S/o/D/o…………….……….……..…………….……. for admission to M.Sc. Medical Imaging TechnologyRadiography Course 2016.

Section Officer (Acad.)

INSTRUCTIONS FOR THE CANDIDATES

Read the following instruction carefully.

DO’s

1. The candidate must bring the admit card (without the envelope) with him/her to secure admission to the Examination hall (failingto do so, shall render him/her liable to expulsion. This shall be checked and verified during the examination).
2. The candidate should bring his/her own fountain pen or black ball point pen for the examination.
3. The candidate must write his/her own Roll Number on the answer sheet in the space provided for it.
4. The candidate should sign the attendance sheet when directed to do so by the invigilator.
5. The candidate must observe silence in the Examination Hall (Any candidate found guilty of disorder or improper conduct shall be liable to expulsion from the Examination Hall).
6. The candidates areunder the disciplinary control of the Superintendent of Examination and required to obey his/her instruction. The candidatewho fails to observe these instructions shall be disqualified and debarred from appearing in this and in any subsequent examination (s) to be held by the Institution.
7. The candidate should leave the roomonly after handing over his/her Test Booklet and Answer Sheet to the Invigilator.

DONT’s

1. Do not bring any article other than specified in the instructions including the envelope in which admit card was mailed to you.
2. Do not copy from the paper of any candidate or permit his/her own papers to be copied or attempt to give or obtain irregular assistance of any kind.
3. No entry into the Examination Hall after beginning of entrance test.
4. Cannot leave the Examination Hall during the initial 90 minutes after distribution of the question paper.
5. Do not take away the question paper/answer sheet out of the Examination Hall.
6. Do not write/scribble or otherwise spoil the furniture and the admit card placed at your desk.
7. Do not carry any text material, printed or written, bits of papers, envelope in which admit card was dispatched or any other material except the admit card, inside the examination hall.
8. Do not copy the questions and answers on the admit card.

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