CANCER INSTITUTE (WIA) Signed photograph to COLLEGE OF ONCOLOGICAL SCIENCES be pasted Adyar, Chennai 600 020 APPLICATION FOR ADMISSION TO MD (RADIOTHERAPY) / DMRT / BOTH MD & DMRT COURSE(S) - (2017-18 SESSION) 1 Name in BLOCK LETTERS with expanded initials at the end. Women candidates should add Selvi / Tmt. as the case may be. Name of the candidate should be underlined. 2 a) Complete address to which any communication is to be sent. b) Telephone no. (with code), if any c) Mobile No., if any d) E-mail id, if any. e) Fax no. (with code), if any. 3 Have you applied for any other course? If so, give details & order of priority. 4 Have you applied for any job? If so, give details & order of priority. 5 Nationality. (Evidence to be produced) 6 a) Present occupation, if any. b) Official address. c) Are you a deputed candidate? (If so, the necessary communication should be enclosed. If not a deputed candidate, a ‘No Objection Certificate’ from the employer should be enclosed) 7 Name, occupation & address of father / mother / husband / wife. 8 Do you belong to the scheduled caste / schedule tribe / socially & educationally backward classes specified in the Tamil Nadu Education Rules? (Evidence to be produced) 9 Date of birth & Age. (Evidence to be produced) 10 Mother tongue. 11 Medical qualification(s). 12 MBBS degree: a) College from which qualified. b) University from which qualified. c) Whether the University is recognized by Medical Council of India / the Tamil Nadu Dr MGR Medical University. d) Register number of the qualifying examination. e) Month & year of passing. f) Class in which passed. (Copies of the MBBS degree certificate, Statements of marks / grades of all MBBS examinations to be enclosed) g) Total duration of the course. (Copy of course certificate to be enclosed) h) Prizes / medals / certificates of merit awarded by the College / University during the MBBS degree. (Evidence to be produced) i) Any failures (Subjects in which failed & number of attempts in each subject to be mentioned). (Attempt certificate from the college to be enclosed, if available). 13 Number & date of Permanent Registration with State Medical Council / Medical Council of India. If the candidate is undergoing the CRRI, shall it be completed on or before March 31, 2017? (Copy of the Permanent Registration Certificate / a self declaration from the candidate who is undergoing CRRI that his / her CRRI will be completed on or before March 31, 2017 to be enclosed) 14 Give details of work done subsequent to passing MBBS mentioning the periods spent in various capacities, if any. (Evidence to be produced) 15 Give details of extra-curricular activities of a professional character / social service nature, if any. (Evidence to be produced) 16 Give details of research work done / papers published in indexed journals, if any. (Evidence to be produced) 17 Give details of distinction in sports, if any. (Evidence to be produced) 18 Are you addicted to smoking / alcohol / drugs? If yes, give details. 19 Marital status: a) Are you married? b) If married, occupation of spouse. c) Number of children. 20 Number & date of Demand Draft enclosed. 21 Have you enclosed two recent conduct certificates, obtained within three months prior to the date of application, in original? 22 Have you enclosed a copy of NEET- PG 2017 Score card showing All India NEET-PG 2017 Rank? 22 If you already possess DMRT: a) College from which qualified. b) University from which qualified. c) Whether the University is recognized by Medical Council of India / the Tamil Nadu Dr MGR Medical University. d) Register number of the qualifying examination. e) Month & year of passing. (Copies of the DMRT certificate, Statements of marks / grades of all DMRT examinations to be enclosed) f) Total duration of the course. (Copy of course certificate to be enclosed). g) Prizes / medals / certificates of merit awarded by the College / University during the DMRT course. (Evidence to be produced) h) Any failures (Subjects in which failed & number of attempts in each subject to be mentioned). (Attempt certificate from the college to be enclosed, if available). i) Date of Registration of additional qualification with State Medical Council / Medical Council of India. (Copy of the Certificate of Registration of additional qualification to be enclosed) Place: Date: Signature of the candidate DECLARATION BY THE CANDIDATE I, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _, do hereby solemnly and sincerely affirm that the statement made and information furnished in my application form, as also in all the enclosures thereto submitted by me, are true. Should it however be found that the information furnished therein is untrue in material particulars, I realize that I am liable for criminal prosecution and I also agree to forego my seat for the course at any time during the course of my study. Station: Date: Signature of the candidate PROSPECTUS Eligibility Candidates who have passed the MBBS degree of the Tamil Nadu Dr MGR Medical University or any other University recognized as equivalent thereto and obtained Permanent Registration from any of the State Medical Councils or Medical Council of India are eligible to apply. Candidates who have passed their MBBS Examinations and are completing the CRRI period on or before March 31, 2017 are eligible to apply. However they should possess the permanent Medical Council Registration Certificates of the States or of India at the time of admission to the course. The candidates who are undergoing CRRI should submit a self declaration that their CRRI will be completed on or before March 31, 2017. If not, their applications will be summarily rejected. Commencement of the courses The courses commence on May 2, 2017. General instructions 1. Candidates should send the completed application with all the necessary documents to the Dean, Cancer Institute (WIA), Adyar, Chennai 600 020. In case of candidates in Government service or candidates being deputed by an Institution / Organization, the application should be made through the relevant proper channel, failing which the application will not be considered. Advance copies will not entitle them to attend the interview. All candidates who are in service, either Government or otherwise, should produce at the time of interview a ‘No-objection certificate’ affirming that the candidates will be released for the course if and when selected. 2. All the entries in the application form must be legibly written by the candidate in his / her own handwriting. 3. An Account Payee Demand Draft dated not earlier than February 5, 2017, in favor of “Cancer Institute (WIA), Chennai – 20”, for the amount shown below, towards Registration Fee should be attached to each application. Application for MD course Rs 1500 Application for DMRT course Rs 1000 Application for both courses Rs 2500 This fee will not be refunded under any circumstances, whether the candidate is considered for selection or not. Candidates are, therefore, advised to satisfy themselves before applying that they fulfil all the conditions for admission to the course prescribed as per regulations. 4. No document enclosed along with the application will be returned. A copy of NEET-PG 2017 Score card showing All India NEET-PG 2017 Rank should be enclosed. Two recent conduct certificates (obtained within three months prior to the date of application) from responsible persons, in original, should be enclosed along with the application form. Xerox copies of all required certificates should also be enclosed. The selection of the candidate will be considered only when all the certificates are in order. The original certificates should be produced at the time of interview for verification. The original certificates once deposited on admission cannot and will not be released to them until they are considered to be no longer required by the Institute. The application with all enclosures securely fastened should be sent superscribed and addressed as follows: “APPLICATION FOR ADMISSION TO MD (RT) / DMRT / BOTH MD & DMRT COURSE(S)” To DEAN CANCER INSTITUTE (WIA) CHENNAI 600 020 The last date for the receipt of completed applications in the office of the Cancer Institute is February 18, 2017. Incomplete applications and applications without enclosures or those received after the due date will be rejected summarily.Cancer Institute (WIA) shall not be responsible for any delay in the receipt or for the loss in transit of application form. 5. Intimation will be sent only to the selected candidates and they should be prepared to join the course immediately on receiving the information of selection. In the matter of selection, the decision of the selection committee shall be final and no appeal shall be entertained on the subject. They should register themselves with the Tamil Nadu Dr MGR Medical University, through the Dean of the Cancer Institute (WIA), presenting all the original documents. Admission to the above course is provisional and subject to the approval of the qualification of the individual candidates and the acceptance of the candidates for registration by the Tamil Nadu Dr MGR Medical University. All candidates provisionally selected shall also be subjected to a medical examination prior to admission. Candidates who have qualified from other Universities should produce Eligibility Certificate from the Tamil Nadu Dr MGR Medical University, Guindy, Chennai 600 032, at the time of admission failing which they will not be considered for admission. In the case of selected candidates from Universities other than the Tamil Nadu Dr MGR Medical University, migration certificates should be produced, if required. Admission of such candidates is provisional and subject to the final approval of their qualifications by the Tamil Nadu Dr MGR Medical University. 6. Candidates before joining the course should pay a deposit amount to be fixed by the Dean of the Cancer Institute towards the recovery of the cost of broken instruments, lost library books etc.