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*ETRrsE 3 r å r o e r R e T a f r a r î s , a r D s MAHARASHTRA

UNIVERSITY OF HEALTH ScIENCEs, NASHIK UNDER-GRADUATE / POST

GRADUATE EXAMINATION FORM

Examination Form No.

To,
The Controller of Examinations, College Code
MUHS, Nashik.
Sir, UG PG
FRESH REPEATER D
(Please /Mark)
Examination to be held in
I request permission to present myself at the ensuing (Class & Course)
Winter/Summer half of 20.. I furnish my details as stated below:-
1,CANDIDATE'S NAMEin Capital Letters (Strictly asperClassXIIor GAZETTE Notification)
L(Surname) (First Name) (Middle Name)

2. MOTHER'S FIRST NAME in Capital Letters:

3. FATHER'S/HUSBAND FIRST NAME in Capital Letters:

4. Candidate's mailing address in CAPITAL Letters only:

IL Pincode:
5. State: LI Contact No.:
6.College Name:
7. Email Addressi ** "*************:" "'**" ******'*"""********
8. Gender : MALE FEMALE U

9. Date of Birth: I
Date Month Year

Paste (do nol staple) Paste (do not staple)

recent Photograph recent photograph
(Size 35mmx 45mm) (size 35mmx 45mmm) Left Hand Thumb Impression
duly attested by the inust not be larger than this
Dean/Principa/Head of the box. Photograph should
Institution. Photograph not be larger than this box
should not be larger than and not older than three
this box and not older than months
three months

ATTESTED
UN-ATTESTED
Signature of the Candidate in running hand, within the box only

NOTE: It is to be ensured that this

Photograph and Signature should match with the Photograph and Signature of Hall Ticket.
10.List of Documents/Itemsto be attached/verified:
Particulars
Document For
s attached For MUHS
College Use only
Yes/No Use only
Pholograph duly altestod by the Dean/Principal
2 Photocopy of marks slatement of lalesl oxaminalon
3. Photocopy of Eligibility loller (For First ycar Studonts only) OR Transfer letler (If
FOR PG STUDENTS, following docunent Is also to bo submitod:. Applicable)
Attendance Certificate of Research Methodology workshop
S.Log book (for Fresh students) (Soft Copy for Medical Faculty & Hard Copy for other
Faculties
Students passed out from other
Universities, UG Degree certificale of respective University
LNOTE:Incomplete Examination form and without documents will be
rejected by the University.
 11. Dress Code:
Sr. Particulars Yes/No*
No.
1.
ehether Candidate want to wearCuitural/Traditional Dressduringthe UniversityExaminations.
arYes,itls mandatory to reamin present at Examination Centre before 01 hour of commencement of
|University examinations for proper frisking (checking)].
a e appearing for the following Subjects (for Subject Name and Subject Code, please refer Theory Time-Table
published by the University on the website)_
Sr. No Subject For Fresh Students OnlyX
Codes Subject Name Attendance % HOD Name HOD Sign
Theory PracticalI

1) I am aware
DECLARATION BY THE CANDIDATE
that, I have to fulfill
criteria of attendance prescribed by the
failing which I shall be held "NOT ELIGIBLE" and will not be allowed to appearUniversity up to commencement of Examination,
for Examination.
2) I hereby declare that I have not availed of any attempt
(including the present one) in excess of the maximum attempts
permissible by Central Council / University for the said examination (wherever
3) Ihereby declare that I have gone through the applicable).
syllabus prescribed and relevant rules of Ordinance 1/2014 (amended) Heads of
Passing which are applicable for the examination for which I am appearing and I accept the same without
(wherever applicable). Reference Ordinance 01/2014 rule 59, 60 & 62 any challenge
for head of passing and Grace Marks) OR as applicable
from time to time.
4) I shall be
responsible if my application form is rejected for any errors, wrong
examination form.
or incomplete entries made by me in the
5) I hereby declare that I shall not claim
any concession
6) I am not
on religious ground.
defying the criteria of the admission order.
7) I am not admitted tp the course after the cut-off date declared
University grant terms. by the for of
8) If"Yes"option is ppt for wearing Traditional/Cultural Dress during Theory
present one hour before commencement of Examinations, Examinations, then I will remain
Place:

Date Signature of Candidate in running hand

CERTIFIED BY THE HEAD OF INSTITUTION

certfy that,
Shri/Smt/Kum. ... s a
*********sstpapp. bonafide student of this college and has
that his/her attendance is not less than as
prescribed by
the satisfactorily attended the classes and
University & respective council norms In lecture
novwever, in prescribed attendance
case Is not fulfill up to teaching and practical work,
ELIGIBLE" against the respective commencement of examinatlon, Hall ticket of the
subject. Candidate will be marked as "NOT
that the candidate hascompleted the academic terms and
appeared in
Tules (wherever applicble). mandatory number of internal assessment tests as per the university
that he/she is not admtted to the course after the cut-off
that the candidate has completed house job (For PG Only-date for grant of terms.
wherever applicable)
that
the information furnished by the said candidate is verified from
appear for University
Examination. his/her documents and that the candidate is Eligible to
Place

Date
Signature & Seal of the Dean/Principal
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