CHATRAPATI SHAHU JI MAHARAJ UNIVERSITY, KANPUR - 208 024
APPLICATION FOR ADMISSION TO THE D.O.M.S. COURSE
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REGIONAL INSTITUTE OF OPHTHALMOLOGY EYE HOSPITAL, SITAPUR - 261 001, INDIA
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To, |
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THE DIRECTOR, REGIONAL INSTITUTE OF OPHTHALMOLOGY SITAPUR EYE HOSPITAL, SITAPUR - 261 001
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Sir, | |||
I hereby apply for admission to the 2 yrs. ensuring course of Diploma in Ophthalmic Medicine & Surgery (D.O.M.S.) The application fee of Rs. 1000/- is enclosed herewith vide bank demand draft No...............................dated ................................... issued by Nationalised Bank (Name of Bank) ................................................. in the name of Finance Officer, Chhatrapati Shahuji Maharaj University, Kanpur, payable at Kanpur. |
Yours Faithfully | ||
Dated: .................... |
(Signature in full) |
PARTICULARS TO BE FILLED IN BY THE CANDIDATE'S OWN HANDWRITING :
(1) | (a) | Full name (in Hindi) | ___________________________________________________________ |
1. | (b) |
Full name (in English Block Letters) |
___________________________________________________________ |
2. | Complete address with telephone numbers & Fax/E-mail | ||
(a) | For correspondence regarding admission | ___________________________________________________________ | |
(b) | Permanent Address | ___________________________________________________________ | |
3. | Father's/Husband's name and complete address | ___________________________________________________________ | |
4. | Date of Birth (christ. era) | ___________________________________________________________ | |
5. | Qualifications | ___________________________________________________________ | |
6. | Religion & Caste | ___________________________________________________________ | |
7. |
Whether Schedule caste/Tribe/ Backward class, if so, details |
___________________________________________________________ | |
8. | Martial Status | ___________________________________________________________ |
(Signature of the Candidates)
9. | Domicile/State of residence | __________________________________________________________ |
10. | Last attended University | __________________________________________________________ |
11. | Name of Medical College from | __________________________________________________________ |
where graduated | __________________________________________________________ | |
12. | Details of compulsory | From____________________________ to _______________________ |
internship | Institution___________________________________________________ | |
13. | Details of Registration as | (a) No.____________________________________________________ |
(b) Name of council___________________________________________ | ||
14. | Experience & engagements after M.B.B.S. (Please write in details) | __________________________________________________________ |
__________________________________________________________ | ||
15. | Details of M.B.B.S. Exam. Marks & Extra attempts (if any) |
Sl. No. | Subject | Max. Marks | Marks Obtained | % percent |
1 | Anatomy | |||
2 | Physiology | |||
3 | Biochemistry | |||
4 | Pharmacology | |||
5 | Path & Bact. | |||
6 | Forensic Med. | |||
7 | S.P.M. | |||
8 | Medicine | |||
9 | Surgery | |||
10 | Obst. & Gyn. | |||
11 | ENT & Eye | |||
12 | ||||
TOTAL : |
DECLARATION:
(Signature of Candidate in full)
Encl.: