Application Form For Mbbs/bds Open Counselling Of Candidates

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APPLICATION FORM FOR MBBS/BDS OPEN COUNSELLING OF CANDIDATES
SELECTED IN AIPMT-UG FOR GOVERNMENT NOMINATION
IN MEDICAL / DENTAL COLLEGES INSIDE / OUTSIDE MANIPUR, 2015
Application form No………………….
Affix photograph
To
duly attested by
a gazetted Officer
The Director,
Health Services,
Size: 3.5 cm x 4.5 cm
Government of Manipur, Imphal
Sir,
I beg to submit an application for counselling to a Medical/Dental College for the MBBS/BDS
course as a Manipur Government Nominee.
(To be filled in English only)
Candidate’s Name in full (in BLOCK LETTERS exactly as entered in X/XII Standard Marks
1.
Statement)
2.
Sex (Tick):
Male [ ]
Female [ ]
3.
Permanent
address:
Pin
Tele/Mob. No.
4.
Present address:
Pin
Tele/Mob. No.
5.
Date of Birth: DD
MM
YY
YYMM
Age on 31.12.2015
6.
Nationality:
7.
Place of birth:
8.
Domicile Status:
(Please tick)
By Birth
Either of the parents are continously residing in Manipur for more than
20 years
Either of the parents are in State Govt. Service or an Institution which is
a body substantially owned or controlled by the Government of Manipur.
9.
Category:
1.
2.
3.
4.
5.
6.
(Please tick)
(1) General, (2) ST, (3) SC, (4) OBC (Meitei etc.O, (5) OBC (Meitei Pangal), (6) OBC (Teli etc.),
It is compulsory to tick one of the appropriate boxes.
Subcategory:
A.
B.
C.
(Please tick)
(A) Meritorious Sports person, (B) Children of Armed Forces personnel and Ex-servicemen,
(C ) Person with disability.
Only candidates belonging to the Subcategory shall tick one of the appropriate boxes.
Father’s Name (in BLOCK LETTERS):
10.
(Name)
(Surname)
Guardian’s Name (in BLOCK LETTERS)-if father is not alive:
11.
(Name)
(Surname)
1

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