BMC 2174
BMC 2174
Affix resent
2. Applicant's full name:
Passport size
(In BLOCK LETTERS) colour
photograph
3. Father’s Name:
5. Contact No. :
9. Religion:
10. Caste and Category of the applicant (put √) (Relevant certificates need to be
enclosed)
UR SC ST EWS
12. Educational Qualification: (The attested photo copies of the certificates and Mark
sheets should be enclosed. Any related technical qualification may also be
mentioned in the same table.)
Sl. Name of the University/Board Year of % of Subjects/ Divn/
No. Exam /Institute passing marks specialization Class/
CGPA
1.
2.
3.
4.
5.
2.
3.
16. a) Have you ever been arrested, prosecuted, kept under detention or bound down
/ fined convicted by court of law of any offence or debarred, disqualified by any
selection / examination or rusticated by any medical college or any other educational
authority / Institution for reason other than traffic offence: (If "yes" give the details)
b) Is any case pending against you in any court of law. Medical College or any
educational authority / Institution at the time of filling up this form?
17. Declaration: I hereby declare that the information furnished above is true, complete and
correct to the best of my knowledge and belief. I understand that in the event any of the
information provided by me is found false or incorrect at any stage, my candidature /
appointment shall be liable for cancellation / termination without notice or any compensation
in lieu thereof.
Place:
Date: Signature of the Applicant