ayurvihar, burla, sambalpur, odisha, india-768017 … brochure for pg 2017.pdf · ayurvihar, burla,...
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ADMISSION BROCHURE.
PG : 2017-18 Veer Surendra Sai Institute of Medical Sciences & Research
Ayurvihar, Burla, Sambalpur, Odisha, India-768017 www.vimsar.ac.in, [email protected]
AIQ SQ
Name of Candidate_________________________________________________________________________
Rank No______________Roll/ Confirmation No_____________Application No/ Testing ID______________
Date of Birth________________________Subject________________________________________________
Reservation Category: GEN SC ST OBC PH GC ES
Phase Institute of Admission
Date of Admission
Date of Relieve
Date of Resignation
Round-I
Round-II
Final Status
PAGE LAY OUT
1. Stepwise Admission Procedure 01
2. Institute Profile Back cover
3. Student’s Bio Data 02
4. Document Submission Sheet 03
5. Document Custodian Certificate 04
6. Undertaking towards Up Gradation/ Undertakings/ Resignation
05
7. Medical Fitness Certificate 06-07
8. Scrutiny Sheet 08
9. Relieve Order 09-10
1. Report at Education section to PG clerk Mr. S.R. Maharana.
2. Put Full signature & Roll No. in the admission attendance sheet .
3. Collect Institute Admission Brochure.
4. Deposit the documents as per list in page…..of brochure.
5. Fill up the relevant pages of Brochure including the cover page.
6. Deposit all necessary documents.
7. Proceed to OPD block of Hospital for Medical Fitness test.
8. Go to Document Verification Desk.
9. Deposit the Admission fees as cash/DD/Net banking if admission is allowed.
10. Submit a copy of the Receipt of fees deposited at Admission Desk.
11. Report for online admission at Computer Desk.
12. Give option for second round in the format of the brochure.
13. Sign in the admission Register.
14. Receive in original the following papers from the office before leaving:
a. Admission letter duly sign by the college authorities
b. Original document retention certificate.
c. Original fee receipt.
15. While resigning or being relieved do ask for return of the retained original documents from
the college by surrendering the original document retention certificate.
16. Admission process may take more than one day.
000
Stepwise Admission Procedure
Pg-01
1. Name of the Student:
2. Date of Birth :
3. Father’s Name :
4. Mother’s Name :
5. Caste (Sub-caste)/Tribe:
6. Occupation of Father:
7. Annual Income of father as per record:
8. Permanent Address:
Vill/Town………………………………………… P.S……………………………………………….…
P.O………………………………………………… Dist……………………………….…………….….
State………………………………………………. Pin…………………………………….……….….
9. Present Communication Address:
Vill/Town…………………………………………… P.S…………………………………………………
P.O………………………………………………… Dist…………………………………………….….
State……………………………………………… Pin…………………………………………….…..
10. Telephone No. of Student Land Line No………………………………………………………
Cell Phone No………………………………………………………
Mail Id……………………………………………………………….
11. Telephone No. of Father/Legal Guardian: Land Line No…………………………………………
Cell Phone No……………………………………………………….
Mail Id……………………………………………………………..….
12. MBBS Details: Year of Passing:……………………………………………..……
College…………………………………………………………….…
University……………………………………………………………..
State……………………………………………………………….….
13. Accounts details for fees refund: Saving Bank Accounts Number……………………………
Name of the Bank…………………………………………………
Name of Branch………………………. IFSC Code………………
Signature of Student…………………………………………
Date: …………………………………………………..
Recent passport
Color Photograph
(Only staple don’t
paste)
Student Biodata
Pg-02
[Tick at appropriate box]
document yes no
1. Admit Card
2. Rank Letter
3. Provisional Allotment Letter
4. HSC Certificate for DOB
5. MBBS Certificate
6. Mark Sheet/1st/2nd/3rd/final MB
7. Internship Certificate
8. MCI registration Certificate
9. Bond
10. TC/CLC
11. Conduct Certificate
12. Caste certificate (ST/SC/OBC)
13. PH Certificate
14. Any Other
I am submitting herewith the documents as listed above in Original (numbering……….) along with photocopy of each for verification and institutional custody for admission in to PG course during the year 2017-18 at Veer Surendra Sai Institute of Medical Sciences & Research, Burla:
I undertake that if, on any day now on, I am found to have submitted any wrong information with regards to the documents and certificates produced by me at the time of admission then my admission to the course stand cancelled and I shall be entitled to legal action as deemed proper by rule
Signature of the Candidate
Roll Number-……………………………….
Name…………………………………………….
Custodian Certificate:- Certified that the original documents (as enlisted above) numbering ……… submitted by the candidate
Dr…………………………………………. during admission is kept in the custody of this office till he/she fulfills
the bond requirments or the candidate gets relieved or resigns from the course.
Signature of PG Clerk Signature of Bursar
Document Submission Sheet
Fitness Certificate [pg-1/2]
Pg-03
[Tick at appropriate box]
document yes no
1. Admit Card
2. Rank Letter
3. Provisional Allotment Letter
4. HSC Certificate for DOB
5. MBBS Certificate
6. Mark Sheet/1st/2nd/3rd/final MB
7. Internship Certificate
8. MCI registration Certificate
9. Bond
10. TC/CLC
11. Conduct Certificate
12. Caste certificate (ST/SC/OBC)
13. PH Certificate
14. Any Other
I am submitting herewith the documents as listed above in Original(numbering….) along with photocopy of each for verification and institutional custody for admission in to PG course during the year 2017-18 at Veer Surendra Sai Institute of Medical Sciences & Research, Burla:
I undertake that if, on any day now on, I am found to have submitted any wrong information with regards to the documents and certificates produced by me at the time of admission then my admission to the course stand cancelled and I shall be entitled to legal action as deemed proper by rule
Signature of the Candidate
Roll Number-……………………………….
Name…………………………………………….
Custodian Certificate:-
Certified that the original documents (as enlisted above) numbering………………submitted by the candidate
Dr…………………………………………. during admission is kept in the custody of this office till he/she fulfills
the bond requirements or the candidate gets relieved or resigns from the course.
Signature of PG Clerk Signature of Bursar
Document Custodian Certificate
Pg-04
I do express my willingness to participate/ not to participate in SECOND ROUND of AIPG counseling for up
gradation.
Signature in Full
Name………………………………………………………………….. NEET-PG Roll Number………………………
Place……………………………………………………..…………. Date………………………………………………
I do hereby undertake to produce the following documents within a time of_______days failing which my
conditional admission into the course will stand cancelled and I shall forfeit my claim for admission into the
college.
1……………………………………………………………………………………………………………………………
2………………………………………………..…………………………………………………………………………
3………………………………………………..…………………………………………………………………………
Signature in Full
Name………………………………………………………………….. NEET-PG Roll………………………
Place……………………………………………………..…………. Date………………………………………………
I do hereby resign from PG Seat subject………………………………………………………..
College……………………………. During counseling period knowing very well that I will have no claim over the
seat in future and I will be out of PG counseling process 2017-18.
Date…………….. Signature in full
Place……………. Name…………………………………………..
Roll No………………………………………….
WILLINGNESS TOWARDS UPGRADATION DURING COUNSELING
BLOCKADE
UNDERTAKING TOWARDS TIME BOUND SUBMISSION OF DEFICIENT DOCUMENTS
BLOCKADE
LETTER OF RESIGNATION
Undertakings
Pg-05
Certified that on this day dated …………………………………. We have examined
Mr./Ms Dr.…………………………………………………………… Rank/Merit No……………..……….. For
physical Fitness for Medical Studies. The findings are detailed below.
1. Name ………………………………………………………………………………………………………….:
2. Father’s Name………………………………………………………………………………………………...
3. Age…………………. 4. Sex………………… 5. Weight…………… 6.. Height………………….
7. Personal Marks of identification:
i………………………………………………………………………………………………………………….
ii…………………………………………………………………………………………………………………
8. Vitals:…………………………………………………………………………………………………………..
9. General Examination:………………………………………………………………………………….…..
10. Cardiovascular System: …………………………………………………………………………………..
11. Respiratory System:………………………………………………………………………………………..
12. Central Nervous System :………………………………………………………………………………...
12. Gastro-intestinal System:………………………………………………………………………………….
13. Vision:…………………………………………………………………………………………………………..
14. Hearing: …………………………………………………………………………………………………….
15. Genitourinary System :………………………………….…………………………………………………
16. Locomotor System:………………………………………………………………………………………..
17. Any Other Disability:……………………………………………………………………………………….
-PTO-
Medical Fitness Certificate [pg-1/2]
Pg-06
18. The Candidate is medically fit/ unfit for admission into MD/MS course.
Date- Sig. of Consultant on Duty, Medicine OPD, VIMSAR, Burla Seal- Name- Designation-
19. The Candidate is medically fit/ unfit for admission into MD/MS course.
Date- Sig. of Consultant on Duty, General Surgery OPD, VIMSAR, Burla Seal- Name- Designation-
20. The Candidate is medically fit/ unfit for admission into MD/MS course.
Date- Sig. of Consultant on Duty, O&G OPD, VIMSAR, Burla Seal- Name- Designation-
21.The Candidate is medically fit/ unfit for admission into MD/MS course.
Date- Sig. of Consultant on Duty, EYE OPD, VIMSAR, Burla Seal- Name- Designation-
22. The Candidate is medically fit/ unfit for admission into MD/MS course.
Date- Sig. of Consultant on Duty, ENT OPD, VIMSAR, Burla Seal- Name- Designation-
23. The Candidate is medically fit/ unfit for admission into MD/MS course.
Date- Sig. of Consultant on Duty, Orthopedics OPD, V IMSAR, Burla Seal- Name- Designation-
General Medicine
General Surgery
O&G (only female)
EYE
ENT
Orthopedics
Medical Fitness Certificate [pg-2/2]
Pg-07
Name……………………………………………………………………………………………………………………
Roll No……………………………………………Application No……………………………………………………..
D.O.B. (DD/MM/YY)………/………./………..
Category: GEN ST SC OBC PH ES GC S.No Document Submitted (original & self-signed photocopy) Verified and Authenticated
1. ID Proof(Original to be returned after verification) Yes No
2. NEET Admit Card (Roll No ______________________________) Yes No
3. NEET Rank Letter (NEET Common Rank________________) Yes No
4. Online generated Self-declaration Slip [only for AP-TL-JK natives ]
[ Verified online- yes/no]
Yes No
5. Provisional Allotment Letter Yes No
6. Relieving Letter (applicable for second round) Yes No
7. MBBS Degree Certificate Yes No
8.. MBBS Mark Sheet [1st,2nd, 3rd & Final] Yes No
9. Internship Certificate(31st March 2017) Yes No
10. Registration Certificate by MCI/State Council(Permanent /Provisional) Yes No
11. Birth Certificate Yes No
12. Transfer Certificate/College Leaving Certificate Yes No
11. Conduct Certificate Yes No
12. Submission of Bond(ME-II-IXM/88/2008, Order No. 3418/H date 03.02.2017) Yes No
13. Two passport size photographs Yes No
14. Reservation Certificate(ST/SC/OBC/PH/GC/ES) Mention:________
Issued by native state [OBC status verified from Central OBC list online -yes/no]
Yes No
15. Declaration to participate in 2nd round counseling Yes No
16. Medical Fitness certificate by the Institute Yes No
17. Receipt of admission fees for Rs.40,300/- [Cash receipt/ DD/e-transfer slip]
DD No./Fee Receipt Number /Online transaction slip no-…………………………..
Dated _____________________
Yes No
18. Other documents (mention)__________________________________
[Eligible for Admission Not Eligible for Admission ] reason thereof.
Signature of Bursar Signature of Scrutiny Officer
Allowed Admission:
Dean & Principal, VIMSAR.
Scrutiny Sheet
Pg-08
OFFICE COPY
Dr…………………………………………………………………………..……..
Roll No…………….……………………………………………………………...
Rank No…………………………………………….. Admitted in PG course in
the …………………………………………………………...…. Department in
Round No. …………………………..………………………… is hereby
relieved on dated…………………………………….. from this Institute due
to reallocation of seats/resignation.
Memo No____________/MC. Dean & Principal
Dated_________2017 VIMSAR,Burla
RELIEVE ORDER OFFICE COPY
Pg-09
Dr…………………………………………………………………………..……..
Roll No…………….……………………………………………………………...
Rank No…………………………………………….. Admitted in PG course in
the …………………………………………………………...…. Department in
Round No. …………………………..………………………… is hereby
relieved on dated…………………………………….. from this Institute due
to reallocation of seats/resignation.
Memo No__________/MC. Dean & Principal
Dated_________2017 VIMSAR
RELIEVE ORDER STUDENT’S COPY
Pg-10
Institute Profile
College Code : OR03
College : VSS Institute Of Medical Sciences & Research [formerly VSS Medical College]
State : Odisha
Name of Institute : VSS Institute Of Medical Sciences & Research
Address of Institute : At/Po-Ayurvihar, Burla, Dist-Sambalpur,Odisha-768017.
Office dial Phone: 0663-2430768 Fax: 0663-2430767
Affiliating University : Sambalpur University, Jyotivihar,Burla,Sambalpur.
Session Start Date : May 01-2017
Admission Amount to be paid (₹) : 40300.00
Annual Fee for AIQ Candidates (₹) : 26600.00 per year for next two years
Stipend 1st Year||2nd Year|| 3rd Year (₹): [All seats are Stipendiary]
39950.00 || 41899.00 || 43848.00
Hostel facility : For Male & Female both
Monthly hostel dues (₹) : 1000.00
Bond conditions : Bond has to be submitted at the time of admission towards post-pg mandatory two year service and penalty on discontinuation of study before completion [as detailed vide Govt. of Odisha Health & Family Welfare Department Resolution No.3418 dated 03-02-2017]
The amount of fee to be reimbursed in case of reallocation or resignation during
the counseling process (₹) :
36000.00
Time period of reimbursement : 90 days after leaving
Institute website : www.vimsar.ac.in
Institute Email Id: [email protected]
Key contact: Mr.Shibaram Maharana, PG Education Clerk Cell-919437558108
Other Information : Available in institute website.