State Quota Form No.
Government of Maharashtra Vilasrao Deshmukh Government Institute of Medical Sciences, Latur Near Rajasthan Vidyalaya, Civil Hospital Campus, Latur Pin code 413512 Tel.(02382-249292) Fax No. 02382-253017 Email:- [email protected] ************************************************************************************************** O.W.N.GMCL/ACAD/MBBS/ADMISSION2020-21/ /20 DATE: - / /2020. ************************************************************************************************** C E R T I F I C A T E Received all originals documents from Shri./Kum. ______and is admitted to First M.B.B.S course in this Medical college from NEET-2020 under State Quota on dated / /2020. He/She has submitted following Original Certificates & two set of attested photocopies separately and College fees at the time of admission. AIR .No: ……………… SML: - ………….. Category: - ……………… Caste: - ……………
S Documents Yes No S Documents Yes No N N Non Creamy Layer Certificate Age/Nationality Certificate/ Valid 1 14 (Valid Dt.31.03.2021) Indian Passport. For (NT1,NT2,NT3,OBC,SBC) Medical Fitness Certificate – 2 Domicile Certificate 15 (Annexure III) Leaving Certificate/ Transfer 3 16 Migration Certificate Certificate 10thStandard Statement of Mark 4 17 Gap Certificate (If Applicable) Sheet. D1/D2/D3:-Ex-servicemen 5 10th Standard Passing Certificate. 18 Certificate, actual service certificate. 12th Standard Statement of Mark D1/D2:- Domicile Certificate of 6 19 Sheet. Defense person. 7 12th Standard Passing Certificate. 20 D3:- Transfer certificate NEET -2020 Rank Letter/ Defense Certificate (If Applicable) 8 21 Mark Sheet. Father/Student Domicile. M.K.B. Border Certificate / 9 NEET -2020 Admit Card 22 Mother tongue Certificate. HA:-Parent Domicile, SSC/HSC 10 Allotment Letter /Selection Letter 23 Hilly area certificate. Handicapped Certificate 11 EWS Certificate 24 (If Applicable) Caste Certificate Aadhaar Card No. 12 25 (If Applicable) ………………………….. Caste Validity Certificate 13 26 (If Applicable) Fee Rs: - 1. D.D. No.1. Date:- / /2020 2. 2. Date:- / /2020 3. 3. Date:- / /2020 All above original certificates check and found correct.
Signature of Scrutiny Officer:- Name of Scrutiny Officer:- Date:- D E A N, V. D. Government Institute of Medical Sciences, Latur State Quota Form No.
Government of Maharashtra Vilasrao Deshmukh Government Institute of Medical Sciences, Latur Near Rajasthan Vidyalaya, Civil Hospital Campus, Latur Pin code 413512 Tel.(02382-249292) Fax No. 02382-253017 Email:- [email protected] ************************************************************************************************** O.W.N.GMCL/ACAD/MBBS/ADMISSION2020-21/ /20 DATE: - / /2020. ************************************************************************************************** C E R T I F I C A T E Received all originals documents from Shri./Kum. ______and is admitted to First M.B.B.S course in this Medical college from NEET-2020 under State Quota on dated / /2020. He / She has submitted following Original Certificates & two set of attested photocopies separately and College fees at the time of admission. AIR .No: ………………………. Category: - ……………… Caste :- …………………….
S Documents Yes No S Documents Yes No N N Non Creamy Layer Certificate Age/Nationality Certificate/ Valid 1 14 (Valid Dt.31.3.2021) Indian Passport. For (NT1,NT2,NT3,OBC,SBC) Medical Fitness Certificate – 2 Domicile Certificate 15 (Annexure III) Leaving Certificate/ Transfer 3 16 Migration Certificate Certificate 10thStandard Statement of Mark 4 17 Gap Certificate (If Applicable) Sheet. D1/D2/D3:-Ex-servicemen 5 10th Standard Passing Certificate. 18 Certificate, Actual service certificate. 12th Standard Statement of Mark D1/D2:- Domicile Certificate of 6 19 Sheet. Defense person.
7 12th Standard Passing Certificate. 20 D3:- Transfer certificate
8 NEET -2020 Rank Letter/ 21 Defense Certificate (If Applicable) Mark Sheet Father/Student Domicile. M.K.B. Border Certificate / 9 NEET -2020Admit Card 22 Mother tongue Certificate. 10 Allotment Letter/Selection Letter 23 HA:-Parent Domicile, SSC/HSC Hilly area certificate. Handicapped Certificate 11 EWS Certificate 24 (If Applicable) Caste Certificate Aadhaar Card No. 12 25 (If Applicable) ………………………. Caste Validity Certificate 13 26 (If Applicable) Fee Rs: - 1. D.D. No.1. Date:- / /2020 2. 2. Date:- / /2020 3. 3. Date:- / /2020 All above original certificates check and found correct.
Signature of Scrutiny Officer:- Name of Scrutiny Officer:- Date:- D E A N, V. D. Government Institute of Medical Sciences, Latur UNDERTAKING REGARDING DEFICIENCY OF CERTIFICATES
I am selected through NEET-2020/ All India Quota for admission at Vilasrao Deshmukh Government Institute of Medical Sciences, Latur, Latur. I have reported on Date: - / /2020.
I undertake to submit the following certificates within one month from the date of admission.
SN Documents
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I am aware of the condition that failure to comply with above mentioned undertaking will lead to official action against me as per the rules and regulations. It shall be my responsibility to produce all necessary documents within stipulated time period and to get eligibility from Maharashtra University of Health Sciences, Nashik.
Name of the Student: - ______
Mobile No.:-
Signature :-
Date : - / /2020.
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I……………………………………………………………………… ………………. Age. ………
R/o,………………………… Tahsil/Tq………………………… Dist. …………………….
I am selected for M.B.B.S. Course at Vilasrao Deshmukh Government Institute of Medical Sciences, Latur, for the year 2020-21 through NEET- 2020 during First/Second/Third/Final round by the Competent Authority/Director Medical Education & Research, Mumbai / DGHS,New Delhi.
Selection list was declared on date / /2020 and I joined Vilasrao Deshmukh Government Institute of Medical Sciences, Latur, on date / /2020.
I am aware of rule of Maharashtra University of Health Science, Nashik that 75% attendance in lectures & 80% attendance in practicals is essential to be eligible for university examination. I will follow the attendance rule.
After completion of M.B.B.S. course, I will complete 01 year bond service of Govt. of Maharashtra. I will submit the bond in prescribed format within one month of admission to the office.
It will be my responsibility to submit necessary documents within 15 days from admission to the course to continue the fee waiver or scholarship which I was already receiving. I will be responsible for any delays in submission of documents of fee waiver or scholarship and for the problems in sanctioning arising because of the delay.
Place : - Latur.
Date : - / /2020.
Name of the student : - ______
Mobile No: - 1. 2.
Signature :-
Name of the Parent/Guardian : ______
Mobile No: - 1.
2.
Signature :-
Student’s E-Mail ID: - GOVERNMENT OF MAHARASHTRA Vilasrao Deshmukh Government Institute of Medical Sciences, Latur OFFICE OF THE DEAN. Admission Year 2020-21 (1st) M.B.B.S.
1 Name of Student Shri/Smt/Kum (As per 10th Marks Statement) 2 Gender Male Female 3 Date of Birth Date/Month/Year :- / / 4 Address for correspondence
5 Permanent Address
Telephone No. /Mobile no./ 6 WhatsApp No.
7 Email id.
8 Domicile State 9 Nationality 10 Name of Maharashtra State Board from which passed the HSC(12th) /Qualifying Examination
11 Name of other State Board from which passed the HSC (12th)/Qualifying Examination. 1) Month & Year of Passing:- ______2) Medium of Exam. :- ______3) Division / Grade :- ______12 th th Details of HSC (12 ) Examination 4) 12 (HSC) Percentage of marks:- 4) 12th PCBE Marks Phy. Chem. Bio Eng. Total ( ) ( ) ( ) ( ) = 5) 12th PCB Percentage of Marks : - 2) NEET Marks Obtained :-
13 Details of NEET- 2020 3) NEET Percentile Score : -
4) NEET Merit List No (AIR):-
14 Quota in which admitted ( AIEE / STATE) Constitutional Category of Admission 15 SC/ST/VJ/NT-1/NT-2/NT3 /OBC/SBC/SEBC/EWS/OPEN 16 Specified Reservation Category DEF/PH/MKB/HA/None 17 Date of Admission / /2020. I hereby declare that the information furnished by me is correct and true to the best of my knowledge and belief. If any information is fraudulent, incorrect or untrue, my admission to the course will be cancelled and Civil/Crime action may be taken against me.
Student Signature.------ GOVERNMENT OF MAHARASHTRA Vilsarao Deshmukh Government Institute of Medical Sciences, Latur STUDENT INFORMATION.
1. Name of Student(In Capital words) :- 2. Gender :- Male / Female Students Latest Passport 3. Father Full Name (In Capital words) :- size Photo. 4. Mother Full Name (In Capital words) :- 5. Date of Birth :- Place of Birth :- 6. Domicile State :- 7. Caste :- Category :- Religion:- 8. Caste Certificate No. :- 9. Caste Validity Certificate No. :- 10. Contact No. : - Mob. No (1):- Mob. No(2):- 11. E-mail id :- 12. Date of Admission :- / /2020 , Quota in which admitted:- 13. Present Address (with Pin code) :- 14. Permanent Address :-
15. Aadhaar Card No. :- 16. Parent / Guardian Name & Address :- 17. Parent / Guardian Mobile no. :-
Previous Education Information
Percentage/ Examining Certificate School Total Marks Percentile Board Year of No of No. &Date SN Exam /College & Grade Name Passing attempts Name A/B/C/D Out Obtained of
1 S.S.C. (10th)
2 H.S.C. (12th)
3 NEET