FORMS TO BE FILLED UP FOR

UNDERGRADUATE MEDICAL
ADMISSION 2022-2023

FOR DETAILED INFORMATION

VISIT

www.mcc.nic.in
&
www.kea.kar.nic.in

1
 Shri Atal Bihari Vajpayee Medical College & Research
Institute, Shivajinagar, Bengaluru
INSTRUCTIONS SHEET
ORIGINAL DOCUMENTS along with THREE SETS OF SELF ATTESTED PHOTOCOPIES and
a SOFT COPY* on a Pendrive along with FIVE PHOTOGRAPHS to be submitted in the following
order.

 OFFICE NOTE
 UNDER GRADUATE STUDENT DATA SHEET
 NEET UG Admit card.
 NEET UG Score card.
 NEET /KEA Allotment Order.
 Domicile Certificate (For state quota candidates only).
 Caste Certificate. (For candidates claiming Reservation)
 Income Certificate of Parent. (For candidates claiming Reservation)
 Study Certificate (For state quota candidates only).
 SSLC/10th Standard Marks Card.
 II PUC/12th Standard Marks card.
 Transfer Certificate.
 Migration Certificate. (For CBSE/ICSE/AIQ Students)
 Eligibility Certificate issued by RGUHS (For CBSE/ICSE/AIQ Students)
Apply Online @ http://www.ecms.online
 Physical Fitness Certificate. (Issued by authorized Government Medical Officer)
 Rural Service Bond. (Rs.100/-e stamp paper Duly Notarised) (Format provided to be
downloaded)
 Anti Ragging Bond. (Rs.50/- e stamp paper Duly Notarised) (Format provided to be
downloaded)
 General Affidavit ( Rs.20/-)(Format provided to be downloaded)
 Photograph. (5 Pass Port Size and Soft copy in JPG less than 45KB)
 Aadhar card. (Photo copy)
 Physical Disability Certificate. (For differently abled candidates issued by competent authority )
 Fee Receipt. (To be obtained at the time of admission in the college)

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 THE FOLLOWING DOCUMENTS TO BE FILLED UP IN CAPITAL LETTERS ONLY
(Format provided to be downloaded)
 OFFICE NOTE.
 STUDENT DATA SHEET.
 DECLARATION.
 FORMAT FOR OBTAINING TRANSFER CERTIFICATE.
 RURAL SERVICE BOND.
 ANTI RAGGING BOND.
 GENRAL AFFIDAVIT
* Note: Scan each of the above documents and Name and Save as individual PDF File in a
single folder bearing the Candidate’s name in a CD And also mail it to
[email protected]

For e Stamp papers

1st party is the candidate &
2nd party is the Director, Directorate of Medical Education, Karnataka for Rural Service Bond

1st party is the candidate &

2nd party is the Director, Directorate of Medical Education, Karnataka for Anti Ragging Bond

1st party is the candidate &

2nd party is the Director, Directorate of Medical Education, Karnataka for General Affidavit

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 No. SABVMCRI/UG/88/2022-23 Dated: 12.09.2022
OFFICE NOTE
Sub: - Admission to Under Graduate Course for the Academic Year – reg.
*****
TO BE FILLED IN CAPITAL LETTERS ONLY
DEGREE MBBS
QUOTA AIQ SEQ Counseling session( Round) I II III MOP UP
UG NEET ROLL NO. UG NEET SCORE

UG NEET PERCENTAGE UG NEET PERCENTILE

ALL INDIA RANK STATE RANK

RESERVATION QUOTA CLAIMED GM / Cat I / Cat II A / Cat II B / Cat II B / Cat III A / Cat III B / OBC / SC / ST

RESERVATION QUOTA
GM / Cat I / Cat II A / Cat II B / Cat II B / Cat III A / Cat III B / OBC / SC / ST
ALLOTTED

Mr./Miss._________________________________________________________has submitted the following Original certificates.

Mrs.
MOTHER’S NAME
Mr.
FATHER’S NAME

FOR OFFICE USE ONLY

FOR OFFICE USE ONLY
SL
PARTICULARS NOT
NO SUBMITTED
SUBMITTED

1 NEET UG ADMIT CARD

2 NEET UG SCORE CARD

3 NEET /KEA ALLOTMENT ORDER

4 DOMICILE CERTIFICATE

5 CASTE CERTIFICATE (FOR CANDIDATES CLAIMING RESERVATION)

6 INCOME CERTIFICATE OF PARENT (FOR CANDIDATES CLAIMING RESERVATION)

STUDY CERTIFICATE
7

SSLC/10th STANDRAD MARKS CARD

8

9 II PUC/12TH STANDARD MARKS CARD

TRANSFER CERTIFICATE
10

4
 MIGRATION CERTIFICATE (FOR CBSE/ICSE/AIQ STUDENTS)
11

ELIGIBILITY CERTIFICATE ISSUED BY RGUHS (FOR CBSE/ICSE/AIQ STUDENTS)

12

PHYSICAL FITNESS CERTIFICATE ( ISSUED BY AUTHORIZED GOVERNMENT MEDICAL OFFICER)

13

14 RURAL SERVICE BOND (RS.100/- E STAMP PAPER-DULY NOTARISED)

ANTI RAGGING BOND (RS.50/- E STAMP PAPER -DULY NOTARISED)

15

16 PHOTOGRAPH (3 PASS PORT SIZE AND SOFT COPY IN JPG LESS THAN 45KB)
No:
17 AADHAR CARD (PHOTO COPY)

No:
18
HYDERABAD
KARNATAKA QUOTA Issued by:

No:
PHYSICAL DISABILITY
19 CERTIFICATE
Issued by:
(for differently abled candidates)

Bank Branch
20 Fee Details
Receipt No. Amount : Date
.

Signature of Candidate Signature of Parent/Guardian

Signature of the Scrutinizing Officer

5
 UNDER GRADUATE STUDENT DATA SHEET (MBBS) ACADEMIC YEAR
Counseling session
MBBS 2022-23 AIQ SEQ I II III MOP UP
(Round)
Sl No PARTICULARS TO BE FILLED IN CAPITAL LETTERS ONLY
1. NAME OF THE CANDIDATE

2. GENDER

3. NATIVE PLACE

4. DATE OF BIRTH WITH AGE

5. MOTHER’S NAME

6. FATHER’S NAME

7. FATHER’S OCCUPATION

8. MOTHER’S OCCUPATION

9. PARENTS INCOME PER ANNUM

10. RELIGION

11. NATIONALITY

12. CASTE

13. SUB-CASTE

PERMANENT ADDRESS
14.

15.
CORRESPONDENCE
ADDRESS

16. PARENT’S MOBILE No.

17. PARENT’S E-MAIL ID

18. MOBILE No.

19. E-MAIL ID

20. AADHAR NUMBER

21. PAN NUMBER

22. BLOOD GROUP & Rh TYPING

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 23. INSTITUTION LAST STUDIED

24. BOARD LAST STUDIED

25. HIGHEST EXAMINATION PASSED II PUC/12th Standard

26. MONTH AND YEAR OF PASSING

27. REGISTRATION NO.( II PUC/12TH STD)

TOTAL MARKS SCORED( II PUC/12TH STD) %

28.
1st Language %
/100
29. 2nd Language %
/100
PHYSICS %
/100
CHEMISTRY %
/100
30.
BIOLOGY %
/100
TOTAL IN PCB %
/300
UG NEET ROLL No. UG NEET RANK
31.
UG NEET UG NEET
UG NEET SCORE %
PERCENTAGE PERCENTILE

32. TYPE OF ALLOTMENT AIQ / SEQ

COUNSELING SESSION
33. I Round / II Round / III Round/MOP UP Round
AIQ/KEA ADMISSION ORDER NO.& DATE
34.
RESERVATION QUOTA CLAIMED
35. GM/ Cat I/ Cat II A/ Cat II B/ Cat II B / Cat III A / Cat III B / OBC/ SC/ ST

RESERVATION QUOTA ALLOTTED

36. GM/ Cat I/ Cat II A/ Cat II B/ Cat II B / Cat III A / Cat III B / OBC/ SC/ ST

HYDERABAD KARNATAKA QUOTA

37. Yes / No
PHYSICAL HANDICAP QUOTA
38. Yes / No
DATE OF JOINING THE UG COURSE
39.
40. FEES PAID
FEES DETAILS
RECEIPT NO.
DATE

Place: Bengaluru
Date:
Signature of Candidate Signature of Parent/Guardian

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 TO BE FILLED IN CAPITAL LETTERS ONLY

DECLARATION

To
The Director cum Dean,
Shri Atal Bihari Vajpayee Medical College
& Research Institute, Bengaluru.

Sir,
MBBS
NAME OF THE CANDIDATE

FATHER’S NAME

UG NEET ROLL NO. UG NEET Rank

TYPE OF ALLOTMENT AIQ / SQ I Round II Round III Round MOP UP Round

CATEGORY CLAIMED GM / Cat I / Cat II A / Cat II B / Cat II B / Cat III A / Cat III B / OBC / SC / ST

CATEGORY ALLOTTED GM / Cat I / Cat II A / Cat II B / Cat II B / Cat III A / Cat III B / OBC / SC / ST

e Mail Mobile No

I___________________________S/o/D/o_____________________________________
have joined the I MBBS course at Shri Atal Bihari Vajpayee Medical College & Research Institute,
Bengaluru at my own risk.

I agree that I will submit the Migration Certificate/Transfer Certificate from the previous
School or College which I have studied within one month from the date of my admission.

Further I have claimed the seat under reservation category _________________________ and
I will be submitting the Validity Certificate and Caste Certificate within one month from the date of
my admission.

Place: Bengaluru
Date:

Signature of Candidate Signature of Parent/Guardian

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 FORMAT FOR OBTAINING TRANSFER CERTIFICATE
Sl.NO. PARTICULARS TO BE FILLED IN CAPITAL LETTERS ONLY
Name of the Candidate
1
Gender
2
Date of Birth with Age / years
3
Father’s Name
4
Mother’s Name
5
Nationality
6
Religion
7
Caste
8
Sub-caste
9
Category
10
Institution last studied
11
Highest examination passed II PUC/12th Standard
12
Registration No.( II PUC/12th Standard)
13
Month & Year Of Passing
14
Date of joining the Shri Atal Bihari
15 Vajpayee Medical College and Research
Institute, Bengaluru.
Place: Bengaluru
Date:
Signature of Candidate Signature of Parent/Guardian
OFFICE NOTE (For office use only)

The above candidate has been admitted to I MBBS Course at Shri Atal Bihari Vajpayee
Medical College and Research Institute, Bengaluru on _____________.The Transfer certificate of
the candidate to be sent to the address mentioned below.
Office Of The Principal,
Shri Atal Bihari Vajpayee Medical College
& Research Institute, Bengaluru

Principal
Shri Atal Bihari Vajpayee Medical College
& Research Institute, Bengaluru
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 TO BE FILLED IN CAPITAL LETTERS ONLY
NOTARISED BOND TO BE EXECUTED ON A STAMP PAPER OF RS.100/-
FOR CANDIDATES WHO SELECT MBBS SEATS IN GOVERNMENT MEDICAL
COLLEGE OR GOVERNMENT SEATS IN PRIVATE MEDICAL COLLEGES
MBBS
NAME OF THE CANDIDATE

FATHER’S NAME

UG NEET ROLL NO. UG NEET Rank

TYPE OF ALLOTMENT AIQ / SQ I Round II Round III Round MOP UP Round

CATEGORY CLAIMED GM / Cat I / Cat II A / Cat II B / Cat II B / Cat III A / Cat III B / OBC / SC / ST

CATEGORY ALLOTTED GM / Cat I / Cat II A / Cat II B / Cat II B / Cat III A / Cat III B / OBC / SC / ST

e Mail Mobile No

I___________________________S/o/D/o________________________________________
(hereinafter called the Natural Guardian of the Student) Resident
of_______________________________on my own volition have joined the allotted MBBS seat at
Shri Atal Bihari Vajpayee Medical College and Research Institute, Bengaluru during the Academic
year on ________________________ (date) do hereby undertake as follows.
In accordance with the Amendment to Rule 11 of the Karnataka Selection of Candidates for
admission to MBBS seats in Professional Educational Institutions Rules, 2006, vide Government
Notification–1. No. HFW 79 RGU 2011, dated: 17.07.2012 and amendment act 2017 dated:
06.07.2017 on completion of the course I am prepared to serve in any Primary Health Center or
Primary Health Unit situated in Rural Areas in the State of Karnataka for a Minimum Period of ONE
year and I will abide to rules and regulations of Government of Karnataka.
The above statement is true and correct. My parent and I hereby undertake to act accordingly.
Place: Bengaluru
Date:
Signature of Candidate Signature of Parent/Guardian

Witness
1 2

Signature Signature
Name Name
Address Address

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 TO BE FILLED IN CAPITAL LETTERS ONLY

NOTARISED BOND TO BE EXECUTED ON e STAMP PAPER OF RS.50/-

ANTI RAGGING BOND

MBBS
NAME OF THE CANDIDATE

FATHER’S NAME

UG NEET ROLL NO. UG NEET Rank

I
TYPE OF ALLOTMENT AIQ / SEQ II Round III Round MOP UP Round
Round
CATEGORY CLAIMED GM / Cat I / Cat II A / Cat II B / Cat II B / Cat III A / Cat III B / OBC / SC / ST

CATEGORY ALLOTTED GM / Cat I / Cat II A / Cat II B / Cat II B / Cat III A / Cat III B / OBC / SC / ST

e Mail Mobile No

I______________________________S/o/D/o___________________________________________
(hereinafter called the Natural Guardian of the Student) resident
of________________________________________________________________________________
__________________________________________________________________________________
hereby give an undertaking that on admission to I MBBS at Shri Atal Bihari Vajpayee Medical
College and Research Institute, Bengaluru during the Academic year , have understood the Rule
No.11 of the Ordinance Governing M.B.B.S Degree Course of Rajiv Gandhi University of Health
Sciences, Karnataka, Bengaluru vide Notification No. ACA/BOS-27/97-98 Dated: 24-03-1998 and I
shall abide by the ordinance.
That no student shall be permitted to join Phase-II (Para Clinical & Clinical) Group of subjects
until he/she passes in the Phase-I (Pre-Clinical) Subject for which he/she will be permitted not more
than four chances (Actual Examination) provided four chances are completed within three years from
the date enrolment.
I shall abide by the Rules of Conduct and Discipline of the institution and abstain from
practicing ragging in any form.
Place: Bengaluru
Date:
Signature of Candidate Signature of Parent/Guardian
Witnesses
1 2

Signature Signature
Name Name
Address Address

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 ANNEXURE ‐ 1
GENERAL AFFIDAVIT
( To be submitted on Rs 20/‐ Bond paper at the time of verification)

I, …………………………………………………...…………….. son /daughter of

…………………………………………………residing at
……………………………………………………………… have appeared for UG NEET
2018 conducted by CBSE, New Delhi with Roll Number __________ and Register Number
……………… and have secured …….. score in the said test. I hereby solemnly declare that
during 2018, I have not taken MBBS / BDS admission in any college allotted by other exam
conducting bodies. I have not surrendered any seat in past UG exams/other UG entrance
exams conducted by central / state Government and various other authorities.

I shall immediately notify the Karnataka Examinations Authority, Bangalore if I am

getting admission in any college through other exam conducting bodies. I shall also not
surrender any seat after the admission at institute level through any seat allotting bodies, if I
need to surrender I shall do so at Karnataka Examinations Authority, Bangalore.

I shall produce all required original documents for verification and submit the same
after allotment of seat to concerned college. I shall not produce/submit fake/concocted
documents for verification or admission. I will forfeit the seat allotted to me and also I am
liable for criminal proceedings if any one of the above information/documents produced by
me is found to be false / incorrect.

Date:
Place : Deponent

Signature of the Candidate Sworn Before Me

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