CANDIDATE INFORMATION SHEET Fill in capital letters only) rer Size Colour Photoeaph with ALL INDIA RANK : signature below (A) PERSONAL DETAILS Name of Candidate: (Sumame) (First name) (Second name) Date of Birth; Place of Birth: Gender: M/F/Others DD/MM/YYYY (City) (State) Permanent Address: Present Address: Mobile No. (Res,) (with City Code), Blood Group : Aadhar Card Number: PAN Number:, Email id: Caste: Religion: ‘Name, Email id & Mobile No. Of Parents/Guardian: Local Emergency Guardian Name and Address Local Emergency Guardian Contact No. Married/Unmarried: (B) UNDER GRADUATION College & University College University Of final M.B.B.S With city & state City’ City: State: State Passing of final M.B.B.S Month: Year: ‘Attempt of final M.B.B.S Date of Internship Completion: Medical Council Registration (State/NMC) Under Graduate Bond Status © POST GRADUATION College & University College: University: Of Post Graduation With city & state City: Cir State: State: Passing date of MD/MS Month: Year Attempt in MD/MS Medical Council Registration (State/NMC): Post Graduate Bond Status ) DM/MCH Admission Details NEET SS Rank: Category: Open/SC/ST/SEBC/EWS Physical Handicap (PwD): Yes/No Course -DM/MCh' Subject: Hospital: (CiviVGCRIUN. Mehta) Sign of Candidate (Or, 7B. J. MEDICAL COLLEGE. AHMEDABAD RMA TO BE FILLED FOR DM/MCh ADMISSION, 2023-24 PROFORMA TO BE FILLED FOR DM/MCh ADMISSION SSS . | ‘Student Name | Gender (M/F) | Date of Birth j Course (Branch) Name | Name of PG Teacher(applicable after joining) if [Exam rank (AIR/State rank) [ NEET SS Roll No. [Quota - All India ‘Name of the entrance exam | Max. Marks (In entrance exam ) | Marks Obtained (In entrance exam ) Percentile (In entrance exam ) Registered Medical Council Medical Council Registration No(MD/MS) Category- OPEN/EWS /OBC/ST/SC/OTHER Physically handicap (Yes/No) [Bank transaction ID | [Bank details from which transaction is done | NAME OF BANK BRANCH 2NAME OF ACCOUNT HOLDER | 3BANK ACCOUNT NUMBER 4IFSC CODE Candidate mobile no. E-mail ID: | Aadhar card no. [Date of Admission ‘Permanent Address: DATE: CANDIDATE’S SIGNATURECis Undertaking i tobe executed on Non-Judicial stamp paper of 4.300 & Submited to CollegeInsute) Undertaking 1, hereby declare that the information/documents given at the time of application/counselling/joining is true. If anything is found to be incorrect or false or misguiding at any time, I understand that my admission shall be cancelled and | may be prosecuted, also I shall be ineligible to apply in future. I shall abide by the results. | read and understood all the rules and regulations of Admission to Super Speciality Medical courses. | shall abide by all the rules and regulations. | accepted all the terms and Conditions pertaining to Admission to Super Speciality Medical courses and I does not have any objections with rules and regulations. | am not engaged in any Super Speciality (DM/MCH/DNBSS) course in any institute at the time of submission of Application form & at present. ARer my admission, If I do not Join the course or resign from course/left the course after Reshuffling Counseling, in such conditions, or in case of implementation of rules 1.3, 1.5, 1.7, 6.5, 6.6(b) 7.8, 7.10, 7.12, of Super Speciality admission, my admission and registration shall be cancelled without any notice thereof. In such situation, | also understand that, 1, My admission and registration will be cancelled without any notice thereof. 2. I will not be eligible for future admission in this University 3. Ihave to pay the whole course fees of all the year/academic terms of College and University. 4. My all deposit amount, Admission fees, tuition fees and university fees are forfeited and | will have no claim on it. 5. Thave to pay Rs. $ Lakhs as a penalty to the Gujarat University 6. I have to fulfill all the conditions of bond as per the rules of Government of Gujarat for Government College. (NOT APPLICABLE FOR M.CH. CARDIO VASCULAR & THORACIC SURGERY AND M.CHl. PAEDIATRICS SURGERY) If do not comply with above conditions, then all the original documents will not be return to me and legal action will be initiated against me. 1 will have obtained Permanent Registration with Medical Council of India or Gujarat Medical Council within one month from the date of his / her admission, failing which the admission of candidate shall be cancelled without any notice thereof; fees forfeited and will not be eligible to apply in future. 1 will have to apply for Gujarat University Registration in the prescribed form duly completed, through the College concerned within one month from the last date of Joining of reshuffling counseling/ final round of counseling. If it does not reach to the University within one month from the last date of Joining of reshuffling counseling/ final round of counseling than one term of Candidate will not be granted and if itis applied later than above time limit. than as per the date of application of Registration, term/terms will not be granted depending upon the date of application of Registration. I will have to submit the topic of Dissertation in the prescribed form duly completed, through the College concerned within three month from the last date of Joining of reshuffling counseling/ final round of counseling. If it does not reach to the University within three month from the last date of Joining of reshuffling counseling’ final round of counseling than one term of Candidate will not be granted and if it is submitted later than above time limit than as per the date of submission of topic of Dissertation, term/terms will not be granted depending upon the date of submission of topic of Dissertation.I will have to participate in Post Graduate Orientation Programme during the first year of residency, within six months of my admission to become eligible to appear in university examination, I shall abide by G.R. No. MCG/1022/SFS-26/) dated 02/04/2022, bond of Rs.$0,00,000/- (Rupees Fifty Lakhs) shall be applicable to Gujarat State Super Speciality Courses. Bond Formalities to be completed and bond agreement documents to be submitted to Post Graduation office within one month of joining. Failing which Head of institute is ‘empowered to cancel the admission. I will have to pay the deposits and fees of College and University as per the rules and regulations of Government of Gujarat and Gujarat University. | know that Hostel accommodation will be provided if available after Final round of Counselling. 1 give undertaking that if I remain absent during P.G. Teacher allotment; I shall have no claim for my Super Speciality teacher of choice. Thave also verified my eligibility before submission of Application for admission to Super Speciality Medical Courses /Super Speciality Medical Admission and also verify my eligibility to apply against category to which I entitled. If through mistakes/error, the forms are accepted and through mistake/error | admitted in Super Speciality Medical Course & if | found to be ineligible, in such case I cannot claim any right or interest arising out of acceptance of form/admission in Super Speciality Medical Course. | abide by the rules and regulations of National Medical Commission, Government of Gujarat, Gujarat University and B.J. Medical College, Ahmedabad. Name: NEET SS 2023 Roll No.: NEET SS 2023 Rank: Date of Birth: Institute Name: Course Name: Residential Address: Mobile Number: Signature: Date:Candidates have to follow and comply following rules and regulation of Gujarat University I. A candidate should have obtained permanent registration with Medical Council of India or Gujarat Medical Council within one month from the date of his / her admission, failing which the admission of candidate shall be cancelled without any notice thereof, fees forfeited and will not be eligible to apply in future, This permanent registration certificate with MCI / GMC should be submitted / checked by respective institute / college where candidate gets admission. 2. Students admitted in post graduate course has to submit the topic of Dissertation in the prescribed form duly completed, through the College concerned within three month from the last date of Joining of reshuffling counseling/ final round of counseling. If it does not reach to the University within three month from the last date of Joining of reshufiling counseling/ final round of counseling than one term of Candidate will not be granted and if itis submitted later than above time limit than as per the date of submission of topic of Dissertation, term/terms will not be granted depending upon the date of submission of topic of Dissertation 3. Students admitted in post graduate course has to apply for registration in the prescribed form duly completed, through the College concemed within one month from the last date of Joining of reshuffling counseling’ final round of counseling If it does not reach to the University within one month from the last date of Joining of reshuffling counseling/ final round of counseling than one term of Candidate will not be granted and if it is applied later than above time limit than as per the date of application of Registration, term/terms will not be granted depending upon the date of application of Registration 4. The PG orientation program is compulsory for all the post graduate students admitted in B.J. Medical College, Ahmedabad affiliated with Gujarat University. All students are required to attend the PG orientation program during the first year of residency, within six months of their admission. In case any student is unable to attend the PG orientation program during the first term, due to a valid reason (duly signed by the PG guide and Head of the department), then PG Director can permit such students to attend the program in second year. But, submission of attendance certificate of PG orientation is mandatory to be eligible for university examination appearance 5. Students admitted in Post Graduate Medical Courses have to complete “Online Research Methods course for Post Graduate Students” as per the MCI norms. 6. If any Post graduate student is found absent for more than 72 hours (in case of before the last date for Completion of entire Admission process) and 15 days (in case of after the last date for Completion of entire Admission process) without leave/ permission / information of competent authority, his / her admission and registration shall be cancelled without any notice thereof, fees forfeited, have to pay the whole course fees, have to pay penalty of university, have to pay bond as per rules of Government Gujarat and he / she will not be eligible to apply in future. 7. A postgraduate students of a postgraduate degree course in broad specialties! super specialties would be required to present one poster presentation, to read one paper at 2 national/ state conference and to present one research paper which should be published / accepted for publication/ sent for publication during the period of his postgraduate studies so as to make him eligible to appear at the postgraduate degree examination. 8. A Candidate who fails four times in medical / dental Postgraduate examination will have to go back and study for full one year under his/her own teacher. Then only the candidate will be permitted to appear in post graduate examination for maximum two trial and if candidate does not clear his/her Post graduate examination than his/her admission/registration will be permanently cancelled. 9. In case of resignation from the post of residency by the candidate or Cancellation of admission due to any reason after the last round counseling process, candidate has to pay Rs. 5 lakhs as a penalty to the Gujarat University. 10, Original Marksheets and other documents etc. of the admitted students submitted at the time of admission shall be retained by the college authority.Date: 16/11/2023 Notice Subject: Super Speciality (DM/MCH) Admission/Joining Process 2023-24 1. Candidates have to submit following Original Documents in 11 X 5” size (A-3 Size) Envelope with details of candidate mentioned on envelope at the time of reporting. a) NEET SS Admit Card 2023(issued by NBE) b) NEET SS Score Card 2023 (issued by NBE) ¢) Allotment Order (issued by MCC) d) All Year MBBS Marksheets (1°, 2", 3" Part I, 3" Part II) ) MBBS Degree Certificate/ Provisional Degree Certificate ) MD/MS Marksheet g) Attempt Certificate (MD/MS/DNB) h) Provisional/Permanent Degree Certificate (MD/MS/DNB) i) Internship Completion Certificate j) Proof of Birth date - School Leaving Certificate/Birth Certificate/SSC Mark Sheet k) Gujarat Medical Council/NMC-MCI Registration Certificate(within one month from joining) 1) PwD Certificate (If Applicable) m) Caste Certificate (If Applicable) n) Non Creamy layer Certificate of financial year pertaining to the period of application from the competent authority as prescribed by the Govt. of India/Respective State Government for OBC/SEBC. (If Applicable) 0) EWS Certificate (If Applicable) p) ID proof (photocopy) ~ PAN/Driving License/Voter ID/PassporvAadhar q) Proof of payment of Caution money deposit (Rs. 1,00,800/-) and first year fees (Rs. 40,000/-) 1) 2 passport size photographs 2. Candidates have to pay the First year college fees (as per Guj. Govt. rules) Rs.40,000/- and Caution Money deposit (1 month stipend) Rs. 1,00,800/- through offline by cash/demand draft in account section at the time of reporting. (Two separate Demand Drafts of Rs.40,000/- & Rs. 1,00,800/- to be made in favor of “Dean, B.J.Medical College, Ahmedabad, payable at Ahmedabad. 3, Candidates should submit the following documents duly filled at the time of Reporting at PG Section of B.J. Medical College. (Formats provided by PG Director office- Attached herewith) - Candidate Information sheet = College Proforma - Undertaking 4. After getting admission order & Certificate of all the original documents submitted at the P.G. Director office, candidates are instructed to go to the concemed department, join the duty and send the joining report duly signed by PG teacher/ H.O.D./ Incharge H.O.D. 2 copies with enclosures (photocopies) to PG Director Office at B.J. Medical College, Ahmedabad (1 Copy with enclosure for college and 1 copy with enclosure for Gujarat University) & Candidate should submit ! copy with enclosure to concerned department and 1 copy should be kept for himself/herself. (Format of Joining Report is attached herewith).Photocopies of following documents to be attached with joining report: a) NEET SS Admit Card 2023(issued by NBE) b) NET SS Score Card 2023 (issued by NBE) ©) Allotment Order (issued by MCC) 4) 12" Mark Sheet e) All Year MBBS Marksheets (1°, 2", 3" Part |, 3" Part II) 1) MBBS Degree Centficate/ Provisional Degree Certificate 2) MD/MS Marksheet h) Attempt Certificate (MD/MS/DNB) i) Provisional/Permanent Degree Certificate (MD/MS/DNB) j) Internship Completion Certificate k) Proof of Birth date - School Leaving Certificate/Birth Certificate/SSC Mark Sheet )) Gujarat Medical Counci/NMC-MCI Registration Certificate(within one month from joining) m) PwD Certificate (If Applicable) n) Caste Certificate (If Applicable) ©) Non Creamy layer Certificate of financial year pertaining to the period of application from the competent authority as prescribed by the Govt. of India/Respective State Government for OBC/SEBC. (If Applicable) p) EWS Certificate (If Applicable) 4) ID proof (photocopy) ~ PAN/Driving License/Voter ID/Passport/Aadhar 5. Date and time of PG Teacher allotment will be informed later on. 6. Candidates are instructed to bring Demand Draft of Gujarat University fees in favor of “Registrar, Gujarat University” payable at Ahmedabad at the time of PG Teacher Allotment. Details of Gujarat University Registration/Enrollment/Tuition fees For Whole Course (Sr.No. Fees (Rs.) I For Girls | 30350 | [2 For Boys | 66350 | 7. Candidates are instructed to bring the “Undertaking” on non-Judicial stamp paper of Rs.300/- and Medical Fitness Certificate in formats (Attached herewith), as provided by PG Director Office, BJMC at the time of PG Teacher Allotment. 8.. Bond Details: Bond applicable to all the students admitted in Super Speciality courses except MCh Cardio Vascular and Thoracic Surgery and MCh Paediatric Surgery Students have to submit bond of Rs. 50,00,000 Fifty Lakhs for providing services for one year at Government Hospitals or GMERS run hospitals in state of Gujarat. Against the bond amount of Fifty lakhs @ student is required to submit Rs. 15 Lakhs bank guarantee or Solvency of propertyworth Rs.15 lac, This bank guarantee or solvency must have validity of @S years which may be ucended if deemed necessary. For the bond amount of Rs.35 lakhs a student also has to submit an undertaking on Rs. 300 notarized stamp paper. & Thoracic d le to the students admitted to M.Ch Cardio ic Surgery wide the G.R. Ni MCAJ1019/SFS-54/5. No Bond appli Surgery and_M.Ch Pedia 09/09/2019. (Annexure-I) 9, Ifthe candidate leaves the course before the completion, he/she will be liable to pay bond penalty (25% of the bond amount) wide G.R. No MCG/1022/SFS-26/) dated 02/04/2022 and penalty as per Gujarat University rules. (Annexure-II) Director Postgraduate Studies & Research B,J. Medical College, AhmadabadOFFICE OF THE DIRECTORATE OF POST SS GRADUATE STUDIES & RESEARCH, B.J.MEDICAL COLLEGE, CIVIL HOSPITAL CAMPUS, AHMEDABAD-16 PIN CODE: 380016 P SG Government of Gujarat Website: www.bimcabd.edu.in, Email: [email protected], Phone No: 07922681024 Date: 20_ To whomsoever it may concern, This is to certify that Dr. ., NEET Roll No ve ., NEET SS Rank . has taken admission through All India Quota on post graduate medical seat at BJ. Medical College, Ahmedabad. All Year MBBS Mark sheets (1%, 24, 3'¢ Part I, 3r¢ Part II) Attempt Certificate MBBS Provisional/Permanent Degree Certificate iv. Internship Completion Certificate y. Provisional/Permanent Degree Certificate (MD/MS/DNB) vi. Birth proof- School leaving certi./ Birth certi./ SSC Marksheet vii. Gujarat Medical Council/NMC Registration Certificate viii. PwD Certificate (If Applicable) ix. Caste Certificate (If Applicable) x. Non Creamy layer Certificate of financial year pertaining to the period of application from the competent authority as prescribed by the Govt. of India/Respective State Government for OBC/SEBC. (If Applicable) EWS Certificate (If Applicable) NEET SS Admit Card 2023 (issued by NBE) NEET SS Score Card 2023 (issued by NBE) xiv. Provisional Allotment letter ( issued by MCC) His/her above mentioned original certificates has been retained at this office since he/she has got admission in DM/MCH course in Director Postgraduate Studies & Research BJ. Medical College, AnmadabadJOINING REPORT(DM/MCH Courses) Date: 120_ From: Name: (In Capital letter) (Surname) (First name) (Second name) Address: To, ‘The Registrar, Gujarat University, ‘Ahmedabad Through: Head of Department & Director, Postgraduate Studies & Research, B.J, Medical College, Ahmedabad. Sir/Madam, 11am submitting herewith my joining report duly signed by H.0.D/In charge H.0.D/P G Teacher with required documents as mentioned in the enclosure below. I am furnishing my details as below Name: (In Capital letter) (Sumame) (First name) (Second name) Mobile No. ‘Overall NEET SS Rank: Category NEET SS Rank: Open/SC/ST/SEBC/EWS ‘Admitted Category: (Oper/SC/STISEBC/EWS) PwD: Yes/No Course Name DM/MCH. Subject/Branch: College & University OF Final M.B.B.S College University With city & state City: City State: State: College & University College: University OF Post Graduation With city & state City City: State: State: Passing date of MD/MS Month: Year: ‘Attempt in MD/MS. Sign of P.G. Teacher/H.0.D/ In charge H.0.D Sign of Candidate (Dr. ) (Dr, ) A 94 "Admission/Aliotment Order of Admitting Authority College Fee/Deposit Receipt Photocopy of Aadhar Card 12 Mark Sheet All Year MBBS Marksheets(1", 4, 3 Part Lat Il) MBBS Degree Cerificate/ Provisional Degree Cerificate MDIMS Marksbeet ‘Attempt Certificate (MD/MS/DNB) Provisional/Permanent Degree Cerificate (MDIMS/DNB) Internship Completion Certificate Proof of Binh date - School Leaving Certificate/Birh Certifies ‘Gujarat Medical Council/NMC-MCI Registration Certificate(wit PwD Cerificate (If Applicable) Caste Certificate (If Applicable) Non Creamy layer Certificate of financial year pertaining to the period of application from the competent authority as prescribed by the Govt. of India/Respectve State Government for OBC/SEBC. (IF Applicable) EWS Certificate (If Applicable) NET SS Admit Card 2023 (issued by NBE) NET SS Score Card 2023 (issued by NBE) Note: Candidates are instructed to submit in person joining report duly signed (Signed by P.G. Tencher/H.O.D//Incharge H.O.D.), 2 copies with enclosures to PG Director Office at BJ Medical College, Ahmedabad (1 Copy with enclosure for College and | copy with enclsoure for Gujarat University) & Candidate should submit 1 copy with enclosure to concerned department and 1 copy should keep for himself/hersel Copy for: (1) Gujarat University (2) PG director BIMC (3) concerned department n one month from joining) Ozer RS zommonee PexCandidate’s Course/Branch: MEDICAL FITNESS CERTIFICATE MEDICAL EXAMINATION OF A CANDIDATE FOR ADMISSION TO MEDICAL POSTGRADUATE COURS 1 hereby certify that I have examined Shri/Kunv/Smt. . ssconsansen ‘a candidate for admission to the medical postgraduate courses and cannot discover that he/she has any disease, constitutional weakness or bodily infirmity except... 1 do not consider this as a disqualification for admission to the Medical postgraduate courses. His/Her age, according to his/her own statement, is. years and appearance years. Marks of identification: Signature Impression of left thumb: (2) Full Name (3) Qualification (Minimum M.B.B.S) Date: _/__/2023 (4) Registration No. 1 RAGGING UNDERTAKING 's and regulations at present in force or that may hereafier be made for governance of postgraduate course and | undertake that during such course, 1 will do nothing either inside or outside the college that will interfere with the orderly governance and discipline. | am also aware that ragging is banned and if found guilty, I shall be Iiable for cancellation of admission and punishment as per rules. st “| hereby agree to confirm to the rule Date: Place: Name of the candidate. (Signature of the candidate) ‘Contact No: