Entry Test I.D.NO Serial No: ___________ Self Finance Self APPLICATION FORM FOR ADMISSION TO st 1 YEAR MBBS/BDS Photo OF PUBLIC SECTOR MEDICAL/DENTAL COLLEGES OF KHYBER PAKHTUNKHWA 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 SELF FINANCE SEATS in MBBS/BDS b. Are you also applying against any reserved seat (Please tick in the relevant box) OPF Backward Areas Disabled Open Merit Any other 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. Have you ever been admitted / studying in any Medical/Dental College in Pakistan. If Yes, mention name of the college: ____________________________________________________________________________________ 11. 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________________14th Preference____________________15th 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 exceptions will be made. The candidate shall be considered only for those colleges for which he/she has shown their preferences. A candidate, under no circumstances will be considered for a college not listed in his/her preferences. Checked by Member of Scrutiny Committee ________________ Chairman Scrutiny Committee _____________________ 1/7 4. Are you Hafiz-e-Quran Yes ☐ No ☐ Year Entry Test Results ID 5. Have you appeared in Entry Test before? Yes ☐ No ☐ If yes, Give details: 6. EDUCATIONAL QUALIFICATION: Qualification Year of Annual / Exam. Marks Total Attempt (s) Board / University Passing Supplementary Roll No Obtained Marks S.S.C (Science) or equivalent F.Sc (Pre-Medical) or Equivalent 7. ETEA MEDICAL ENTRANCE TEST 2018: Entry Test ID Marks Otained Percentage 8. 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 Hafiz-e-Quran SSC 10% F.Sc 40% Entry Test 50% Deduction Merit Score Marks Weightage Weightage Weightage 2/7 8. Father’s Income and Occupation_______________________________________________________________________ 9. Guardian’s Name___________________________________Income & Occupation______________________________ 10. Exact Relationship with Guardian______________________________________________________________________ 11. Income tax or land revenue paid by your parents/guardian a. Income tax____________b. Land revenue______________ 12. Were you ever involved in criminal proceeding in a court of LAW? If Yes, attach brief account ____________________ 13. Name of School from where SSC Passed ________________________________________________________________ 14. 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 - - - - 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. 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 at the time of admission. 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 = Ayub Medical College, Abbotabad BKMC=Bacha Khan Medical College, Mardan BKDS=Bacha Khan Dental Secion, Mardan. BMC=Bannu Medical College, Bannu. GKMC = Gajju Khan Medical College Swabi KGMC = Khyber irls Medical College (For Girls only) GMC = Gomal Medical College KCD = Khyber College of Dentistry KIMS = KMU Institute of Medical Sciences, Kohat KIDS = KMU Institute of Dental Sciences, Kohat KMC = Khyber Medical College Peshawar SMC = Saidu Medical College Swat NMC=Nowshera Medical College Nowshera 3/7 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. 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. 7. 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. 8. Applications forms with any false statement by candidate will be rejected. 9. If any certificate submitted by the candidate is found false, or forged during his/her study period, his/her admission