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    Application Form DMAT - 2015

    Uploaded by

    Rahul Singh
    This document is an application form for admission to various medical and allied health programs in private colleges in Madhya Pradesh, India. It requests information such as the applicant's name, date of birth, gender, course choice, contact details, educational qualifications, details of application fee payment, signature, and a declaration agreeing to abide by admission rules. It provides instructions on correctly filling the form and warns applicants to beware of unauthorized agents or institutions claiming to guarantee admission through improper means.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Application Form DMAT - 2015

    Uploaded by

    Rahul Singh
    87 views4 pages
    This document is an application form for admission to various medical and allied health programs in private colleges in Madhya Pradesh, India. It requests information such as the applicant's name, date of birth, gender, course choice, contact details, educational qualifications, details of application fee payment, signature, and a declaration agreeing to abide by admission rules. It provides instructions on correctly filling the form and warns applicants to beware of unauthorized agents or institutions claiming to guarantee admission through improper means.

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    This document is an application form for admission to various medical and allied health programs in private colleges in Madhya Pradesh, India. It requests information such as the applicant's name, date of birth, gender, course choice, contact details, educational qualifications, details of application fee payment, signature, and a declaration agreeing to abide by admission rules. It provides instructions on correctly filling the form and warns applicants to beware of unauthorized agents or institutions claiming to guarantee admission through improper means.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    87 views4 pages

    Application Form DMAT - 2015

    Uploaded by

    Rahul Singh
    This document is an application form for admission to various medical and allied health programs in private colleges in Madhya Pradesh, India. It requests information such as the applicant's name, date of birth, gender, course choice, contact details, educational qualifications, details of application fee payment, signature, and a declaration agreeing to abide by admission rules. It provides instructions on correctly filling the form and warns applicants to beware of unauthorized agents or institutions claiming to guarantee admission through improper means.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 4

    APPLICATION FORM FOR ADMISSION TO MBBS/BDS/BPT/B.SC.

    NURSING
    AND OTHER ALLIED PARAMEDICAL COURSES 2015
    IN PRIVATE DENTAL AND MEDICAL COLLEGES OF MADHYA PRADESH

    DMAT - 2 0 1 5
    DMAT - 2015 APPLICATION FORM

    Application Form No.

    Read instructions given in the Prospectus carefully.


    Use BLUE / BLACK Ball Point Pen to fill up the Form.
    Fill the Form in English using CAPITAL letters, except signature.
    Do not fold, staple or clip the Form.
    DD of Rs 1500/- as Examination Fee in Favor of APDMC Payable at Bhopal
    Application form no. will be allotted by APDMC on receipt of Application Form

    NAME OF THE APPLICANT

    DATE OF BIRTH

    SEX (TICK ONE)

    COURSES

    (TICK ONE)

    CHOICE FOR TEST CENTRE

    MBBS / BDS
    DATE

    MONTH

    YEAR

    MALE

    1st

    BPT

    FEMALE

    2nd

    B.SC.NURSING
    OTHER ALLIED
    PARAMEDICAL
    COURSES

    ASSOCIATION OF PRIVATE DENTAL AND MEDICAL


    COLLEGES OF MADHYA PRADESH, BHOPAL

    NAME OF FATHER / MOTHER

    ADDRESS FOR CORRESPONDENCE [DO NOT REPEAT NAME]

    CITY

    STATE *

    STD CODE

    TELEPHONE NUMBER

    MOBILE NUMBER

    PHOTO GRAPH
    Paste
    your
    recent
    passport
    size
    color
    photograph must be
    taken on or after 01.
    01.2015 With a play
    card indicating Name
    and Date, of taken
    photograph.

    LEFT THUMB IMPRESSION


    OF APPLICANT

    SIGNATURE OF APPLICANT

    [With Blue/Red Stamp Pad Ink ]

    Sign within the box without touching the edges

    NOTE:
    .

    PIN CODE

    PLEASE TURN OVER LEAF

    *STATE CODE WRITE FOR MADHYA PRADESH MP, UTTAR PRADESH UP, DELHI DL AND AS THE CASE MAY BE.

    NATIONALITY

    DMAT - 2015 APPLICATION FORM

    EDUCATIONAL / QUALIFICATION
    EXAM
    PASSED /
    APPEARED

    BOARD / UNIVERSITY

    YEAR

    SUBJECT

    MAX.
    MARKS

    MARKS
    OBTAINED

    % OF MARKS

    PHYSIC

    CHEMISTRY
    BIOLOGY
    TOTAL
    ENGLISH

    DETAILS OF DEMAND DRAFT [EXAMINATION FEE]


    D.D. NO.

    DATE

    RS.

    NAME OF THE BANK OF D.D.

    ASSOCIATION OF PRIVATE DENTAL AND MEDICAL


    COLLEGES OF MADHYA PRADESH, BHOPAL

    BRANCH AND CITY

    NAME OF TEST CITIES


    CENTRE

    CENTRE

    CENTRE

    CODE

    CENTRE
    CODE

    AHMEDABAD

    01

    JAIPUR

    07

    BHOPAL

    02

    LUCKNOW

    08

    DELHI

    03

    PATNA

    09

    GWALIOR

    04

    RAIPUR

    10

    INDORE

    05

    REWA

    11

    JABALPUR

    06

    UJJAIN

    12

    DECLARATION: I hereby declare that all the particulars stated in this Application Form are true to the best of my

    knowledge and belief. I have read and understood all provisions of admission and agree to abide by them. I also
    affirm that I fulfill the eligibility requirements for the course/s applied. In event of submission of fraudulent, incorrect
    or untrue information or suppression or distortion of any fact likes educational qualification, marks, nationality etc. I
    understand that my admission / degree is liable for cancellation. I further understand that my admission is
    purely provisional subject to the verification of the eligibility conditions.

    @@@@@..@@@@@.@@

    @@@@@@@@@.

    SIGNATURE OF PARENT / GUARDIAN

    SIGNATURE OF APPLICANT

    ASSOCIATION OF PRIVATE DENTAL AND MEDICAL COLLEGES OF MADHYA PRADESH, BHOPAL

    %&% psrkouh %&%


    ,lksfl;sku vkWQ izkbZosV MsaVy ,oa esMhdy dkWyst e/;iznsk dh lEiw.kZ Hkkjro"kZ esa vU;
    dksbZ czkap ugha gS laLFkk dk dksbZ Hkh vf/kdkjh@deZpkjh dk;kZy; ds ckgj tkdj dke ugha dj
    ldrk vkSj uk gh fu;efo:) izosk fnykus dk vf/kdkj j[krk gSa A ,sls esa vxj dksbZ
    O;fDr@,stsalh@laLFkk gekjh laLFkk dk izfrfuf/k gksus dk nkok dj ,lksfl;sku vkWQ izkbZosV
    MsaVy ,oa esMhdy dkWyst ds i{k esa izosk ds uke ij fdlh Nk=@Nk=kvksa@vfHkHkkodks ls
    vkosnu i= izkIr djsa vFkok Nk=@Nk=kvksa@vfHkHkkodks dks MsaVy@esMhdy dkWyst esa izosk nsus
    dk vkoklu ns] ,sls O;fDr@,stsalh@laLFkk voS/k xfrfof/k;ksa }kjk Nk=@Nk=kvksa@vfHkHkkodks
    dks xqejkg dj tkylkth dj ldrs gS ,slh voS/k xfrfof/k;ksa ds fy, ,lksfl;sku vkWQ izkbZosV
    MsaVy ,oa esMhdy dkWyst fdlh Hkh izdkj ls mRrjnk;h ugh gksxk A
    iznsk ds futh fpfdRlk@nar egkfon~;ky;ks esa MhesV dksVs dh lhVksa ij izosk
    ,lksfl;sku vkWQ izkbZosV MsaVy ,oa esMhdy dkWyst e/;iznsk }kjk vk;ksftr MhesV ijh{kk esa
    izkIr esfjV ds vk/kkj ij lSUVykbt dkWmflfyax ds ek/;e ds }kjk gh gksxsA esMhdy@MsaVy
    dkWystks esa izosk gsrq bPNqd Nk=@Nk=kvksa@vfHkHkkodks dks psrkouh nh tkrh gS fd os fdlh
    voS/k xfrfof/k;ksa esa u iMs ,oa tkylktks ls cps vU;Fkk os Lo;a mRrjnk;h gksxsA
    Important Caution
    Association of Private Dental and Medical Collage (APDMC), Madhya
    Pradesh do not have any other Branch Office all over India. The employees
    of APDMC are not allowed to work outside the office nor they have any
    right to secure admission against the rules. Any person /agency / institution
    claiming to be representative of the Association of Private Dental and
    Medical Collage and assuring to secure admissions in Private Medical and
    Dental College either through influence or by use of unfair and unethical
    means could be touts / agents / racketeers trying to deceive by false promises
    to secure admissions. The APDMC is not responsible for any such illegal
    activity.
    Admissions to DMAT Quota in Private Medical / Dental Colleges of
    the State through DMAT Examination conducted by the APDMC are
    through centralized Counseling based purely on merit. Candidates aspiring
    for admissions in Private Medical / Dental College are advised to beware of
    unscrupulous elements and do not fall in their trap or else they will be solely
    responsible.
    APDMC

    ASSOCIATION OF PRIVATE DENTAL AND MEDICAL COLLEGES OF MADHYA PRADESH, BHOPAL

    IMPORTANT INSTRUCTION
    1. The candidates are advised before filling up the form to ensure that they
    fulfill All the eligibility and qualifying conditions with respect to qualification
    etc. for Admission to the course applied for.
    2. The candidates are required not to attach/enclose any document with the
    Application Form. They shall be required to produce the same at the time of
    Counseling.
    3. The Association shall not be responsible for the Application Form lost in transit
    And

    or

    received

    after

    due

    date

    and

    in

    mutilated/turn

    condition.

    correspondence shall be entertained in this respect.


    4. Incomplete Application Form Will be rejected.
    5. Read instructions given in the Prospectus carefully.

    CHECK LIST:
    1. Application Form has been filled up correctly and signed at desired places.
    2. Demand Draft

    (CTS DD Only)

    of Rs. 1500/- as Examination fee in favour of

    APDMC, Bhopal has been enclosed with Application Form.


    3. No certificate has been submitted along with Application Form.
    4. Latest colored photograph has been pasted as per instructions.
    5. Photocopy of the Application Form has been taken and kept for future
    references.
    6. Declaration column has been signed by the candidate and parent/guardian.
    7. Left Thumb impression with Blue/Red stamp pad ink has been taken.

    POSTAL ADDRESS:
    To,
    The Controller of Examination
    DMAT OFFICE
    E-2/51, ARERA COLONY,
    OPPOSITE HABIBGANJ RAILWAY STATION
    BHOPAL -462016 (M.P.)

    No

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