Serial No: ______Entry Test I.D.No.

FATA

APPLICATION FORM FOR ADMISSION TO st 1 YEAR MBBS/BDS Photo OF PUBLIC SECTOR MEDICAL/DENTAL COLLEGES OF SESSION 2018-19

(This form should be filled in BLOCK letters) Note: Please read the instructions and admission policy before filling the form. a. This form is for applying against FATA SEATS in MBBS/BDS b. Are you also applying against any other seat, if yes please mention

1. Name: ______(As per SSC (Science) or equivalent certificate in block letters) 2. Father’s Name: ______3. Date of Birth: ______/______/______4. Gender: ______5. District / Agency of Domicile: ______6. Date of Issue of Domicile: ______7. Present Postal Address: ______Phone 1(Mobile/Cell)______Phone 2(Mobile/Cell)______Phone 3(Land Line)______Phone 4(Land Line)______8. Permanent Address: ______

______

9. E-mail: ______

10. Order of priority of Colleges for admission in MBBS/BDS:(Use abbreviation for the names of colleges as given) 1st Preference______2nd Preference______3rd Preference______4th Preference______5th Preference______6th Preference______7th Preference______8th Preference______9th Preference______10th Preference______11th Preference______12th Preference______13th Preference______2nd Preference______15th Preference______16th Preference______17th Preference______18th Preference______19th Preference______20th Preference______21th Preference______22th Preference______23th Preference______24th Preference______25th Preference______26th Preference______27th Preference______Note: A candidate will give his/her preference in order of priority for the medical/dental colleges in the designated space provided in the admission form which once given shall be final and cannot be changed subsequently. This condition is mandatory and neither any subsequent change is entertainable nor any exception will be made. The candidate shall be considered only for those colleges for which he/she has shown their preference.

Checked by Member of Scrutiny Committee ______Chairman Scrutiny Committee ______

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11. Have you ever admitted/studing in any Medical/Dental College in : if yes, Mention name of the college______12. Are you Hafiz-e-Quran Yes ☐ No ☐

Year Entry Test Results 13. Have you appeared in Entry Test before? Yes ☐ No ☐ If yes, Give ID details:

14. EDUCATIONAL QUALIFICATION:

Qualification Year of Annual / Exam. Marks Total Attempt (s) Board / Passing Supplementary Roll No Obtained Marks University S.S.C (Science or equivalent) F.Sc (Pre-Medical) or Equivalent

15. ETEA MEDICAL ENTRANCE TEST 2018: Entry Test ID Marks Otained Percentage

16. Application Processing Fee: Rs. Bank Deposit Slip No: ______MCB Branch/Code: ______Dated:______

======FOR OFFICE USE ONLY: Receipt No. Dated: Office Stamp: ______

REMARKS/DEFICIENCIES

ADJUSTMENT OF MARKS

SSC 10% F.Sc 40% Entry Test 50% Hafiz-e-Quran Marks Deduction Merit Score Weightage Weightage Weightage

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17. Father’s Income and Occupation______18. Guardian’s Name______Income & Occupation______19. Exact Relationship with Guardian______20. Income tax or land revenue paid by your parents/guardian a. Income tax______b. Land revenue______21. Were you ever involved in criminal proceeding in a court of LAW? If Yes, attach brief account ______22. Name of School from where SSC Passed ______23. Name of College from where F.Sc Passed ______

Signature of the Applicant’s Father/Guardian Signature of the Applicant CNIC No: CNIC No or Registration No of Computerized Form B - - - -

VERIFICATION OF DOMICILE OF FATA CANDIDATES BY POLITICAL AGENT/ COMMISSIONER OF THE RESPECTIVE AGENCY

Certify that Mr./Ms.______S/D/O ______belongs to recognized tribe of ______section ______and his/her father is a permanent bonafide resident of the tribal area of ______Agency, sub- section ______village ______and he/she is an eligible candidate to avail himself/herself of the MBBS/BDS seat reserved in the Medical/Dental Colleges of Khyer Pakhtunkhwa for FATA candidate. The domicile Certificate wherein category ______has been issued to the above named applicat vide No______dated______by this office and is hereby verified.

Sign & Stamp of PA/ Commissioner

Documents Required The following documents must be attached with the application form in the following sequence. The documents & certificates must be attested by Gazetted Officer/ Nazim. The stamp of the officer must bear full name, designation and current place of duty.  Two Copies of detailed Marks Certificate of examination on the basis of which admission is sought. (F.Sc or equivalent).  An equivalence certificate from the Inter-Board Committee of Chairmen, Islamabad, if the qualifying certificate is from an Institute abroad.  A copy of Hafiz-e-Quran certificate if the candidate claims to be Hafiz-e-Quran.  A copy of Secondary School Certificate Examination (Science /equivalent).  Two copies of the domicile certificate as mentioned in the entry test form.  A copy of Domicile certificate of father of the applicant. If father is not alive, then copy of the domicile certificate of mother and the death certificate of father or an affidavit on judicial stamp paper declaring the death of father duly attested by oath commissioner and district nazim/Grade 17 or above Government officer as per specimen given in the admission policy.  A Copy of Computerised National Identity Card / Computerised Form-B of the candidate copied on full size paper.  A copy of computerized National Identity Card of father of the applicant copied on full size paper. If father is not alive, then a copy of the National Identity Card of the mother and guardian.  Migration certificate from the concerned board/University.

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 A copy of attempt certification from concerned BISE, if the period between SSC and F.Sc is more than two sessions.  Three passport size coloured photographs of the applicant with name, father name, and attestation on the back.  Undertaking on judicial stamp paper of Rs. 35/- duly attested by notary public/political agent as per specimen given in the the admission policy.

IMPORTANT NOTES/INSTRUCTIONS

Separate application form must be filled along with complete set of documents if you are applying for more than one categories of seat.

1. Candidates not having domicile of Khyber Pakhtunkhwa are not eligible to apply for admission on Khyber Pakhtunkhwa seats. 2. All applicants must appropriately fill and sign the admission form. Incomoplete/forms in any respect will not be accepted. Avoid overwriting/cutting, while filling the form. 3. Select your choice in order of priority from the following institutions. ADS = Ayub Dental Section, Abbotabad AMC = , Abbotabad BKMC=Bacha Khan Medical College, Mardan BKDS=Bacha Khan Dental Secion, Mardan. BMC=, Bannu. GKMC = Gajju Khan Medical College Swabi KGMC = Khyber irls Medical College (For Girls only) GMC = KCD = Khyber College of Dentistry KIMS = KMU Institute of Medical Sciences, Kohat KIDS = KMU Institute of Dental Sciences, Kohat KMC = SMC = Swat NMC=Nowshera Medical College Nowshera,

AIMC= Allama Iqbal Medical College, Lahore AJKMC=Azad Jammu and Kashmir Medical College, Muzaffarabad BMCQ= Bolan Medical College Quetta DCD=De’ Montmorency Dental College, Lahore FJMC=Fatima , Lahore (For Girls only) KEMC=King Edwards Medical College PMC=Punjab Medical College Faisalabad MBBSMC=Mohtharma Benazir Bhutto Shaheed Medical College, Mirpur NMC(Multan) = Nishtar Medical College Multan (Reciprocal Seat for Punjab) PMC(Rawlakot) = , Rawlakot RMC=Rawalpindi Medical College QMC=Quaid e Azam Medical College Bahawalpur SMBBMC=Shaheed Mohtharma Benazir Bhutto Medical College, Larkana

4. The undertaking/agreement must be filled by the candidate on judicial bond of Rs 35/- and should be duly attested by the political agent/ first class magistrate and attached with the application form. The specimen proforma for undertaking is attached with this form. 5. Appications should reach the office Chairman KMU Admission Committee on or before the closing date and time. Application received after the due date and time will not be entertained for admissions. No forms will be accepted through mails/courier. 6. An application form without the locations of schools/college certificate from DEO Education schools counter signed by the Political Agent/DC of the concern district will not be processed. 7. Applicant must study the admission policy of Khyber Pakhtunkhwa Medical and Dental colleges available on KMU website (www.kmu.edu.pk) in order to understand the rules and regulations regarding entrance test, admissions procedure, distribution of seats, examination/tution etc. 8. Domcile, DMC of Fsc (Pre-Medical)/Equivalent examination, SSC and other certificates once submitted with entry test form can not be changed and shall be considered as final. Revision of result or improvement of marks by the board/IBCC after the finalization of merit list shall not affect the merit list of admission of current year in any way. All the above mention certificates issued after the dates fixed for the receipt of application forms shall not be entertained. 9. Applications forms with any false statement by candidate will be rejected. 10. If any certificate submitted by the candidate is found false, or forged during his/her study period, his/her admission shall be cancelled forthwith and he/she shall be blacklisted for admission to any professional colleges in Khyber Pakhtunwa Further legal action can be taken against the student under the existing criminal laws.

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UNDERTAKING / AGREEMENT

(To be filled by the candidate on Judicial Bond of Rs. 35/- and duly attested by the Deputy Commissioner / Political Agent / DCO).

I Mr. / Miss.______Son/Daughter/Wife of______Resident of ______do hereby solemnly undertake to abide by the following:

i. That I have read the admission policy of KMU for Khyber Pakhtunkhwa Medical/Dental Colleges and hereby agree to conform to all provisions of the statutes of the College or statutes and rules as may hereafter be framed by the appropriate authorities. ii. That the information furnished in, and documents attached with the application form, are correct, and I fully understand that at any time during the course of my study, if it is found that any information is in-correct or any document produced at the time of admission are false, which would have rendered me ineligible for admission under the rules, my name shall immediately be struck off from the college roll and legal proceedings started against me. iii. That I shall, in case my name is struck off under clause (ii) above, not be entitled to claim refund of any fee paid by me. In addition I shall pay to the Principal as liquidated damages at the rate of Rs. 100,000 (one Lac) per year of my studies in Khyber Pakhtukhwa Medical/Dental Colleges. iv. That I shall, have minimum attendance of 75 percent, diligently apply myself to acquire and develop the skill necessary for the practice and advancement of my study in order to qualify for examination and I will not be promoted to the next higher class unless I have cleared all the subjects. v. That I shall maintain identity as a student of the college by wearing college uniform. I shall participate fully and whole heartedly in games and extracurricular activities. vi. That hostel accommodation will be provided subject to availability, in case of non- availability of hostel accommodation, I will not ask for any accommodation. vii. That I will not indulge in politics of any type and will not be a member of any political party/ organization / students Federation, holding a gathering, meeting or taking out procession in any part of Campus. I understand that my failure to observe this clause of undertaking would result in cancellation of my admission / expulsion from the college, and that the decision of the prinicipal in this regard will not be challenged in any cour of Law except the Supreme court of Pakistan. viii. That I shall never use violence, threat of violence and pressure in any dispute with others, all means and methods shall only be logic, persuasion, petition, appeal, revision, review and other legal and peaceful method for settlement of differences and disputes. ix. That in any dispute with students, teachers and employees of the college I shall accept the judgment of the committee constituted by the principal/government. x. Further, I do hereby solemnly undertake to refrain from:- a. Doing anything which may cause injury or insult to head, teacher, officers and other staff of institution. b. Holding a gathering, meeting and taking out procession in any part of Campus other than areas specified for the purpose. c. Allowing or abetting the entry to the premises of the college of expelled students, anti- social elements or others whose presence in the Campus could cause conflict amongst the students. d. Bringing into the Campus, consuming or encouraging consumption of alcoholic products, drugs and narcotics and indulging in acts of moral turpitude. e. Bringing or keeping any type of weapons within the University / Institute premises. f. Using or occupying any room or part of any building of the Institution without lawful authority. g. Subletting any hostel room to unauthorized persons. h. Damaging any University / Institute property including building, equipment and vehicles etc. in any manner. i. Indulging in any violent or any other unsuitable activities even outside the campus of Medical/Dental colleges, which may bring bad name to the college. j. From all such acts and deeds as might bring disgrace and bad name to the college. xi. In case I am reported to be guilty / involved in any of the aforesaid activities during my stay in the college, the college authorities can rusticate me from the college temporarily or expel me permanently. I will not try to create law and order situation or instigate the students of the Institute or of any other institution against the action taken by the institute and further more I will not go to any Court of Law in this regard. In case of my expulsion from college I shall pay to the Principal as liquidated damages at the rate of Rs.100,000 (one Lac) per year of my study in the college. xii. If it is reported that I have not honoured the decision of the college authorities as described above, I shall be liable to pay Rs. 2,00,000/- (Two Lac) per year of my study in the Institute as damages to the government of Khyber Pakhtunkhwa. xiii. In case there is any dispute between me on one hand and the administration of the college on the other hand regarding my involvement in a disciplinary or political matter or regarding the imposition of any penalty or damages on me, the matter shall be referred to the Principal, as the sole arbitrator and his decision in such capacity shall be final and shall not be challenged in any court of law. xiv. I will abide by the decision of the college Authorities. In case I am found guilty of indiscipline, defamation, disrespect of the Staff and other anti-institutional activities. xv. I understand that if it is found that I was not entitled for admission according to Khyber Medical Univeristy Admission policy at any stage of MBBS/BDS course or if it is found that I was not entitled for admission in preference to the other candidates who applied for admission, my admission will stand canceled. xvi. I solemnly declare that I do not have double domicile certificate.

Deponent Signature of the Student: Name: ______Father’s Name: ______CNIC No: ______Permanent Address: ______Dated: ______/______/______Note: Place of Domicile entered in the online Registration from on KMU website and the one produced with the admission form must be the same, otherwise the candidate shall be deemed disqualified.

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TO BE FILLED BY FATHER/GURDIAN OF THE CANDIDATE

I ______Son/Daughter/Wife of ______and Father/Mother/Husband/Guardian of ______hereby fully endorse the undertaking given by my Son/Daughter/Wife/Ward and assure that he / she will abide by this undertaking during his / her stay in the college. i. I also make myself liable to pay Rs. 1,00,000 ( one hundred thousand ) per year of his / her study in the Institute in case of any breach of the above mentioned undertaking by my Son/ Daughter/Wife/Ward, Mr./ Miss.______. ii. I______Father/Mother/Husband/Guardian of Mr./Miss______assure that my Son/Daughter/Wife/Ward will not indulge in politics of any type and will not be a member of any political party/organization/students Federation nor will he / she attend any meeting of such organizations. Such involvement on his / her part may lead to his / her expulsion from the college, and that the decision of the Principal in this regard will be final. SIGNATURE OF THE FATHER/GAURDIAN OF THE STUDENT Signature: ______Full Name: ______CNIC No: ______Father’s Name: ______Present Postal Address: ______

Witness-1 Witness-2

Signature: ______Signature: ______

Name: ______Name: ______

CNIC No: ______CNIC No: ______

Father’s Name: ______Father’s Name:______

Present / Postal Address: ______Present / Postal Address: ______

______

Permanent Postal Address: ______Permanent Address: ______

______

ATTESTED Signature and Stamp of Political Agent/First Class Magistrate

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