hkkx&v ¼vh;fkhz }kjk hkjk tk,½ scrutiny profoma and... · 3 qksvks izek.k&i=@vfhkys[kksa dh...

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1 QksVks izk:i&1 izek.k&i=@vfHkys[kksa dh LØwVuh] laca/kh izksQkekZ ¼fpfdRlk@nar fpfdRlk egkfo|ky;ksa esa izos’k gsrq½ Hkkx&v ¼vH;FkhZ }kjk Hkjk tk,½ eS ?kks"k.kk djrk gw ¡ fd eSus e/; izns 'k fpfdRlk @nar fpfdRlk ikB;dze esa izos 'k gsrq e/;izns 'k jkti= ¼vlk/kkj.k½ esa izdkf'kr e/;izns 'k fpfdRlk f’k{kk izos ’k fu;e] 2018 ,oa e/;izns 'k jkti= esa fnukad 19 twu 2019 dks izdkf'kr la'kksf/kr fpfdRlk f’k{kk izos ’k fu;e] 2018 dks HkyhHkkafr i<+ rFkk le> fy;k gSA eq>s e0iz0 ds fpfdRlk@nar fpfdRlk egkfo|ky;ksa esa lapkfyr ikB~;Øe dh tkudkjh gSA rRi'pkr gh fu;eksa es a fn;s x;s mica/kksa ds v/khu dkmaflfyax esa Hkkx ys jgk@jgh gw ¡A eSa vkoaVu ds vuqdze esa izos’k gs rq ewy izek.ki=@ vfHkys[k izLrqr dj jgk@jgh gw A 1@ NEET UG_____ ijh{kk dk jksy ua cj --------------------------------------------------------------- ------------------ 2@ vkYk bf.M;k esfjV lwph Øeka d ---------------------------------------------------------------------------------------- 3@ iwjk uke% ---------------------------------------------------------------------------------------- 4@ ekrk@firk@ifr@vfHkHkkod dk iwjk uke ,oa irk ---------------------------------------------------------------------------------------- 5@ Js .kh ¼vukjf{kr@vuqlwfpr tutkfr@vuqlwfpr tkfr@------------------------------------------------------------------------------- vU; fiNM+k oxZ @vkfFkZd :i ls detks j oxZ E.W.S.) 6@ izoxZ& ¼lSfud] Lora=rk laxzke lSukuh] fnO;ka x]½ % -------------------- 7@ vH;FkhZ dk eksckbZy Qksu ua- ,oa bZ&esy vkbZ-Mh-ua ------------------------------------------------------------------ 8@ vH;FkhZ dk cSad [kkrk ua----------------------------------------------- vkbZ-,Q-,l-lh- dks M ua------------------------------------- iksVZy ij ntZ Qhl VªkUtsD’ku ua --------------------------------- ewy izek.k i=@vfHkys [k tks izLrqr dj jgs gSa muds lkeus lgh ¼ ½ dk fpUg yxk;sa 1- p;u ijh{kk gsrq vH;FkhZ ds iath;u dh Qks Vks ;qDr izfr vFkok izos'k i=A 2- gkbZ Ldwy ,oa gkW;j lsds .Mjh ¼10$2½ vFkok led{k ijh{kk dh va dlwphA 3- d{kk 11oha dh vadlwph 4- vk;q izek.k ds fy;s gkbZ Ldwy] vFkok led{k ijh{kk mRrh.kZ djus ds izek.k i=@vad lwph dh ewy izfr ftlesa vk;q dk mYys[k gksA 5- vH;FkhZ dh Qks Vks ;qDr vkbZMhA 6- e/;izns 'k dk ewy fuoklh@LFkkuh; fuoklh gksus laca/kh l{ke vf/kdkjh }kjk tkjh izek.k&i=A vH;FkhZ ds O;Ld u gksus dh n'kk esa mlds ekrk@firk ds ewy fuoklh izek.k i= esa vH;FkhZ dk uke va fdr gks A 7- l{ke vf/kdkjh }kjk tkjh e/;izns 'k jkT; esa vkjf{kr Js .kh ¼tkfr izek.k&i=½ dk LFkk;h tkfr izek.k&i=A 8- vkfFkZd :i ls detks j oxZ ¼EWS½ ds vH;fFkZ;ksa dks e/;izns 'k jkT; 'kklu ds l{ke vf/kdkjh }kjk orZeku o"kZ esa tkjh fd;k x;k izek.k i=A

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  • 1

    QksVks

    izk:i&1 izek.k&i=@vfHkys[kksa dh LØwVuh] laca/kh izksQkekZ

    ¼fpfdRlk@nar fpfdRlk egkfo|ky;ksa esa izos’k gsrq½

    Hkkx&v ¼vH;FkhZ }kjk Hkjk tk,½

    eS ?kks"k.kk djrk gw¡ fd eSus e/; izns'k fpfdRlk @nar fpfdRlk ikB;dze esa izos'k gsrq e/;izns'k

    jkti= ¼vlk/kkj.k½ esa izdkf'kr e/;izns'k fpfdRlk f’k{kk izos’k fu;e] 2018 ,oa e/;izns'k jkti= esa

    fnukad 19 twu 2019 dks izdkf'kr la'kksf/kr fpfdRlk f’k{kk izos’k fu;e] 2018 dks HkyhHkkafr i

    fy;k gSA eq>s e0iz0 ds fpfdRlk@nar fpfdRlk egkfo|ky;ksa esa lapkfyr ikB~;Øe dh tkudkjh gSA

    rRi'pkr gh fu;eksa esa fn;s x;s mica/kksa ds v/khu dkmaflfyax esa Hkkx ys jgk@jgh gw¡A

    eSa vkoaVu ds vuqdze esa izos’k gsrq ewy izek.ki=@ vfHkys[k izLrqr dj jgk@jgh gwA

    1@ NEET UG_____ ijh{kk dk jksy uacj ---------------------------------------------------------------------------------

    2@ vkYk bf.M;k esfjV lwph Øekad ----------------------------------------------------------------------------------------

    3@ iwjk uke% ----------------------------------------------------------------------------------------

    4@ ekrk@firk@ifr@vfHkHkkod dk iwjk uke ,oa irk ----------------------------------------------------------------------------------------

    5@ Js.kh ¼vukjf{kr@vuqlwfpr tutkfr@vuqlwfpr tkfr@-------------------------------------------------------------------------------

    vU; fiNM+k oxZ @vkfFkZd :i ls detksj oxZ E.W.S.)

    6@ izoxZ& ¼lSfud] Lora=rk laxzke lSukuh] fnO;kax]½ % --------------------

    7@ vH;FkhZ dk eksckbZy Qksu ua- ,oa bZ&esy vkbZ-Mh-ua------------------------------------------------------------------

    8@ vH;FkhZ dk cSad [kkrk ua----------------------------------------------- vkbZ-,Q-,l-lh- dksM ua------------------------------------- iksVZy

    ij ntZ Qhl VªkUtsD’ku ua---------------------------------

    ewy izek.k i=@vfHkys[k tks izLrqr dj jgs gSa muds lkeus lgh ¼√½ dk fpUg yxk;sa

    1- p;u ijh{kk gsrq vH;FkhZ ds iath;u dh QksVks ;qDr izfr vFkok izos'k i=A

    2- gkbZ Ldwy ,oa gkW;j lsds.Mjh ¼10$2½ vFkok led{k ijh{kk dh vadlwphA

    3- d{kk 11oha dh vadlwph

    4- vk;q izek.k ds fy;s gkbZ Ldwy] vFkok led{k ijh{kk mRrh.kZ djus ds izek.k i=@vad

    lwph dh ewy izfr ftlesa vk;q dk mYys[k gksA

    5- vH;FkhZ dh QksVks ;qDr vkbZMhA

    6- e/;izns'k dk ewy fuoklh@LFkkuh; fuoklh gksus laca/kh l{ke vf/kdkjh }kjk tkjh

    izek.k&i=A vH;FkhZ ds O;Ld u gksus dh n'kk esa mlds ekrk@firk ds ewy fuoklh izek.k

    i= esa vH;FkhZ dk uke vafdr gksA

    7- l{ke vf/kdkjh }kjk tkjh e/;izns'k jkT; esa vkjf{kr Js.kh ¼tkfr izek.k&i=½ dk LFkk;h

    tkfr izek.k&i=A

    8- vkfFkZd :i ls detksj oxZ ¼EWS½ ds vH;fFkZ;ksa dks e/;izns'k jkT; 'kklu ds l{ke

    vf/kdkjh }kjk orZeku o"kZ esa tkjh fd;k x;k izek.k i=A

  • 2

    9- orZeku o"kZ dk rglhynkj@uk;c rglhynkj }kjk tkjh vk; izek.k&i= vFkok vH;FkhZ

    }kjk LogLrk{kfjr ?kks"k.kk i= ¼vU; fiNMk oxZ ds vH;fFkZ;ksa esa dhzeh@ukWudhzeh ys;j ds

    fu/kkZj.k gsrq½ ¼;fn ykxw gks½A

    10- fnO;kax izoxZ gsrq vkj0ih0MCY;w0Mh0 ,DV 2016 ds vUrxZr cSap ekdZ fMl,fcfyfV ds

    fy;s fdlh Hkh jkT; ds fnO;kaxrk dsUnz vFkok dsUnz ljdkj ds fofufnZ"V fnO;kaxrk dsUnz

    ls tkjh fd;k x;k fnO;kaxrk dk izek.k i=A

    11- lSfud izoxZ ds vH;FkhZ dks dekUMsaV ¼lsokjr lSfud dh n’kk esa½ vFkok ftyk lSfud

    dY;k.k cksMZ ¼lsokfuo`Rr vFkok e`r lSfud dh n’kk esa½ }kjk tkjh fd;k x;k izek.k i=]

    izk:i 2 ¼v½ ] izk:i 2 ¼c½ vFkok izk:i 2 ¼l½A

    12- Lora=rk laxzke lSukuh vH;FkhZ dks lacaf/kr ftyk dysDVªsV }kjk tkjh fd;k x;k izek.k

    i=] izk:i&3 A

    13- vfuoklh Hkkjrh; dksVs ls lhV vkoafVr gksus dh n'kk esa izksQkekZ 4]5]6 ds vuqlkj fn;k

    tkus okyk 'kiFki= A

    14- e/; izns’k ds vU;= fdlh jkT; ls ewy fuoklh ¼LFkkuh; fuoklh izek.k i=½ izkIr ugha

    djus laaca/kh ’kiFk i= ,oa fdlh vU; jkT; ls ewy fuoklh dk ykHk ugha fy;s tkus laca/kh

    'kiFki= izksQkekZ&7A

    15- lhV fyfoax ckW.M@ xzkeh.k lsok ca/k i= izksQkekZ&8

    vH;FkhZ ds gLrk{kj ds lkFk iwjk uke rFkk irk

  • 3

    QksVks

    izek.k&i=@vfHkys[kksa dh LØwVuh] laca/kh izksQkekZ

    Hkkx&c ¼LdzwVuh ¼Nkuchu½ lfefr }kjk Hkjk tk,½

    izekf.kr fd;k tkrk gS fd LdzwVuh ds le; mifLFkr vH;FkhZ dk QksVks ,oa gLrk{kj dk lh-

    ch-,l-bZ-@,u-ch-bZ- ubZ fnYyh }kjk izsf"kr NEET esa lfEefyr ijh{kkfFkZ;ksa ds QksVks ,oa gLrk{kj MkVk ls feyku djus ds ckn lgh ik;k x;k gS vFkok fHkUurk ikbZ xbZ gS A

    fHkUurk dh fLFkfr esa fVIi.kh &---------------------------------------------------------------------------------

    izekf.kr fd;k tkrk gS fd vH;FkhZ }kjk izLrqr fd, x, vfHkys[[email protected] i=ksa dh tkap dh xbZ

    rFkk vfHkys[[email protected] i=ksa dh Lo izekf.kr Nk;kizfr;ksa ds nks lsV fjdkMZ gsrq tek dj fy;s x;s gSaA ,oa

    tek fd;s x;s ewy nLrkostksa dk izek.ki= vH;FkhZ dks iznku fd;k x;kA

    lR;kiu ds i'pkr~] vH;FkhZ vkoafVr lhV ij izos'k ds fy;s ik= gS

    vFkok

    fuEu vfHkys[[email protected]&i= izLrqr ugha djus ds dkj.k@;k vU; dkj.kksa ls vkoafVr lhV ij izos'k ds fy;s

    vik= gSa %&

    1-----------------------------------------------------------------------------------------------------

    2------------------------------------------------------------------------------------------------------

    3------------------------------------------------------------------------------------------------------

    izos’k lfefr ds v/;{k ds

    gLrk{kj e; fnukad] uke] inuke

    izos’k lfefr ds lnL; ds

    gLrk{kj e; fnukad] uke] inuke

    izos’k lfefr ds lnL; ds

    gLrk{kj e; fnukad] uke] inuke

  • 4

    izk:i&2 ¼v½

    ¼vuqlwph&3 ¼12½ Lukrd ikB;dze gsrq½

    feysVªh ilZu laoxZ ¼,e-ih-½ gsrq izek.k i=

    HkwriwoZ lSfud

    lanHkZ Øekad--------------------- fnukad---------------------

    ;g izekf.kr fd;k tkrk gS fd Jh@Jherh-------------------------------------------------------------------------------------------

    -----------tks izos’k ijh{kk NEET UG o"kZ --------------------------------------------------------------------------------------------------------------------

    ds vk/kkj ij ------------------------------------------------------ikB~;Øe esa izos'k ds fy;s vH;FkhZ Jh@dqekjh ---------------------

    ---------------------------------------- ds firk@ekrk gSa

    Fky lsuk@ok;qlsuk@ukSlsuk ds@dh ,d HkwriwoZ lSfud gSaA lsokfuo`fRr@lsokeqfDr ds

    le; og-----------------------------------------in ij Fks@Fkh A mudk lfoZl Øekad-----------------------------------

    ------------------------------FkkA lsok ds nkSjku og LFkk;h :i ls fodykax gks x;s gaS@lsok ds nkSjku

    mudh e`R;q o"kZ------------------------ esa gks pqdh gSA og e/;izns’k ds LFkkuh; fuoklh

    gSa@ugh gSa ¼tks ykxw u gks mls dkV nsa ½

    LFkku---------------------- ftyk lSfud dY;k.k vf/kdkjh ds gLrk{kj

    fnukad----------------

    ---------------------------------------------------------------------

    ¼dk;kZy; lhy½

  • 5

    izk:i & 2 ¼c½

    ¼vuqlwph&3 ¼12½ Lukrd ikB;dze gsrq½

    e/;izns'k esa@e/;izns'k ds ckgj vU; jkT; esa dk;Zjr lSfud

    lanHkZ Øekad------------------------- fnukad-------------------------

    ;g izekf.kr fd;k tkrk gS fd Jh@Jherh---------------------------------------------------------------

    --------------tks izos’k ijh{kk NEET UG o"kZ ------------------- ---------------------------------------------------------------------------

    --ds vk/kkj ij ------------------------------------------------------ikB~;Øe esa izos'k ds fy;s vH;FkhZ Jh@dqekjh -

    -------------------------------------------------------------------------------------------------------- ds firk@ekrk gSa

    v& Fkylsuk@ok;qlsuk@ukSlsuk esa---------------------------------------------------------------in ij lfoZl Øekad--------------

    -------------- ds v/khu dk;Zjr lSfud gSa vkSj e/;izns'k esa fLFkr izfrj{kk bdkbZ esa inLFk gSaaSA

    og e/;izns’k ds LFkkuh; fuoklh gSaA

    vFkok

    c& Fkylsuk@ok;qlsuk@ukSlsuk esa-----------------------------------------------in ij lfoZl Øekad------------------------------

    ds v/khu dk;Zjr lSfud gSa vkSj og e/;izns'k jkT; ds ckgj fLFkr izfrj{kk bdkbZ esa

    inLFk gaSA og e/;izns’k ds LFkkuh; fuoklh gSaA

    vFkok

    l& Fkylsuk@ok;qlsuk@ukSlsuk esa-----------------------------------------------in ij lfoZl Øekad------------------------------

    ds v/khu dk;Zjr lSfud gSaA og e/;izns'k jkT; ds LFkkuh; fuoklh ugha gS ijUrq

    e/;izns’k esa fLFkr izfrj{kk bdkbZ esa fnukad------------------------------------ ls lsokjr gSaA

    LFkku---------------------- gLrk{kj % vkfQlj dekafMax---------------------------

    fnukad---------------- ---------------------------------------------------------------------

    ¼dk;kZy; lhy½

  • 6

    izk:i&2 ¼l½

    ¼vuqlwph&3 ¼12½ Lukrd ikB;dze gsrq½

    HkwriwoZ lSfud }kjk LFkk;h :i ls e/;izns'k esa vf/kokflr gksus laca/kh izek.k i=

    lanHkZ Øekad---------------------- fnukad----------------------

    esjs le{k izLrqr fd;s x;s izek.k ds vk/kkj ij izekf.kr fd;k tkrk gS fd

    Jh@Jherh@dqekjh ¼mEehnokj dk uke½------------------------------------------------------------------------------------------ tks izos’k

    ijh{kk NEET UG-o"kZ-------------------------- ds vk/kkj ij ¼ikB;dze dk uke½----------------------------ikB;dze esa

    izos’k ds fy, mEehnokj gSa] Jh@Jherh ¼firk@ekrk½-------------------------------------------------------------------------------------

    -ds@dh iq=@iq=h gSa] tks Fkylsuk@ok;qlsuk@ukSlsuk esa -------------------in]lfoZl dzekad-------------------------- ds

    v/khu lsokjr jgdj lsokfuo`Rr gq, gSa vFkok lsokfuo`fRr ds Ik’pkr@mudh e`R;q ds Ik’pkr ~ muds

    ifjokjtu -----------------------------------¼LFkku½]rglhy-----------------------ftyk----------------------esa vf/kokflr gks x, gSaA

    LFkku&&&&&&&&&&&&& ftyk lSfud dY;k.k vf/kdkjh ds gLrk{kj

    fnukad&&&&&&&&&&&& &&&&&&&&&&&&&&&&

    ¼dk;kZy; lhy½

  • 7

    izk:i& 3

    ¼vuqlwph&3 ¼13½ Lukrd ikB;dze gsrq½

    Lora=rk laxzke lsukuh izoxZ gsrq izek.k i=

    lanHkZ Øekad---------------------- fnukad-----------------------

    ;g izekf.kr fd;k tkrk gS fd Jh@Jherh----------------------------------------------------------------tks izos’k ijh{kk

    NEET UG o"kZ ------------------- -----------------------------------------------------------------------------ds vk/kkj ij -----------------------------------

    -------------------ikB~;Øe esa izos'k ds fy;s vH;FkhZ Jh@dqekjh ----------------------------------------------------------------------------------

    ----------------------- ds firk@ekrk gSa A

    rFkk

    Jh@Jherh ¼vH;FkhZ ds firk@ekrk dk uke½-----------------------------------------------------------------------------------

    Jh@Jherh ¼Lora=rk laxzke lsukuh dk uke½ ------------------------------------------------- ds iq=@iq=h gSaA

    rFkk

    Jh@Jherh ¼Lora=rk laxzke lSukuh dk uke½ --------------------------------------------------------------- dk uke e/;izns'k

    ds ftyk --------------------------------------------- ¼ftys dk uke½ esa la/kkfjr Lora=rk laxzke lSukuh dh iath esa

    Øekad--------------------------------------------- ij iathd`r gSaA

    LFkku&&&&&&&&&&&& gLrk{kj %

    fnukad&&&&&&&&&&& ¼ftyk dysDVj@ftyk dysDVj }kjk vf/kdr̀ vf/kdkjh½

    dk;kZy; dh Li"V eksgj

  • 8

    PROFORMA-4 (izk:i&4)

    [As per Schedule 3 item 11(iv) (v) ] NOTARIZED AFFIDAVIT BY NRI CANDIDATE

    (to be executed on rupees 1,000/- non judicial stamp paper)

    (For admission in the NRI quota seats in Private Medical and Dental Colleges of MP State) 1) I, (Name of candidate) _______________________ Son of

    Shri/Smt._______________________ aged ________ years, who is seeking admission in _____________________________ course through NEET _______________, NEET Testing ID ____________ under NRI quota seats in ______________________ private college, holding ___________________________ passport and residing at ___________________________________, mobile number ________ email id_________ , am an NRI. Proof of being NRI:- (any one)

    i) OCI Card

    ii) NRI Status certificate issued by embassy/consulate general in the admission year

    iii) Copy of passport

    OR

    2) I am being sponsored by ____________ Son of /Daughter of___________ who is an NRI and

    is my _____________ by relation as indicated below :-

    S.no Relationship with candidates Tick Mark

    1 Parents

    2 Grandparents, (paternal/maternal )

    3 Real Uncle / Aunt (paternal/maternal )

    4 Real Brother/ Sister

    OR

    3) I am taken as a ward by_____________________S/o,/ D/o, _________________ who is an NRI and i am related to him in the following manner…………… (describe the relationship).

    Sponsor will bear the entire fee to be paid for my education for the entire tenure of the programme.

    Date Place Signature of Candidate

    Name _____________ Address_____________

    Note :- 1. choose any one of the three alternatives applicable. 2. in case the candidate is a minor the affidavit has to be signed by a parent or legal

    guardian of the candidate in the proforma given.

  • 9

    PROFORMA-5 (izk:i&5)

    [As per Schedule 3 item 11(iv) (v) ] NOTARIZED AFFIDAVIT BY GUARDIAN / SPONSOR

    (to be executed on rupees 1,000/- non judicial stamp paper)

    (For admission in the NRI quota seats in Private Medical and Dental Colleges of MP State) 1) I, (Name of guardian/ Sponsor) _____________________hereby, declare that Mr/ Ms -----------

    ------------(Name of candidate) Son of Shri/Smt_____._______________________ aged ________ years, who is seeking admission in _____________________________ course through NEET _______________, NEET Testing ID ____________ under NRI quota seats in ______________________ private college, holding _____________________________________ passport and residing at ___________________________________, mobile number ________ email id_________ , is an NRI. Proof of being NRI:- (any one)

    i) OCI Card

    ii) NRI Status certificate issued by embassy/consulate general in the admission year

    iii) Copy of passport

    OR

    2) He is being sponsored by ____________ Son of /Daughter of___________ who is an NRI and is related to the candidate by relation as indicated below :-

    S.no Relationship with candidates Tick Mark

    1 Parents

    2 Grandparents, (paternal/maternal )

    3 Real Uncle / Aunt (paternal/maternal )

    4 Real Brother/ Sister

    OR

    3) He is taken as a ward by_____________________S/o,/ D/o, _________________ who is an NRI and related to him in the following manner…………… (describe the relationship).

    Sponsor will bear the entire fee to be paid for my education for the entire tenure of the programme.

    Date Place Signature of Legal Guardian/ Sponsor

    Name _____________ Address_____________

    Note :- Choose any one of the three alternatives applicable..

  • 10

    PROFORMA-6 (izk:i&6)

    [As per Schedule 3 item 11 (v) ] NRI/OCI SPONSORSHIP CERTIFICATE

    (Applicable for candidates sponsored by NRI/OCI) The candidate is required to submit the following NRI/OCI sponsorship certificate from the sponsorer duly notarized in the country of residence of NRI/OCI at the time of admission.

    I, ……………………………………………………………………Son/Daughter of Mr./Mrs.

    ………………….…….………........ aged about ……………years, do hereby declare that I am

    a Non-Resident Indian (NRI)/ an Overseas Citizen of India (OCI) and I am herewith enclosing

    photocopy of my valid passport/ OCI card duly counter signed by the Indian embassy/ high

    commission.

    That my present address is:………………………………………………………………...

    ……………………………………………………………………………………………………

    …………….………………………………………………………………………….……………

    ………………………………………….……….PhoneNo.:……………………………….……

    Country:…………………Email:…………………………………………………………………

    …… ….....

    That I have taken Mr. /Ms………………………………………………………………...........

    Daughter/Son of……………………………………………………………………………...........

    Address………………………………………………………………….......................…………

    as my ward, who is taking admission in....................................................course through

    NEET......................(Year)............................,NEET testing ID.....................................under NRI

    Quota........................... and that I wish to sponsor him/her as a candidate in the NRI category for

    admission in the private medical college in Madhya Pradesh.

    That I undertake to bear the entire fee of Mr./Ms…………………………….to study in the

    UG/PG

    Programme till he/she successfully completes the program. That the candidate

    Mr/Ms. ……………………….. is related to me as……………….. (describe relationship).

    I am holding Passport No………………of country ……………………………………….. date

    of issue……………………..……………....…………………Declared on this ……………….

    day of …………….2019.

    Signature of the Sponsor ………………………. Name……………………………………………… Email:- ……………………………..………………

    Place of Residence……………….………………

    ……………………………………………………

    Verification by notary Verified that the contents of this affidavit are true to the best of my knowledge and be verified at______________ (place) on this the ________(day) of ______(month), _________(year). Name _____________________ Solemnly affirmed and signed in my presence on this___________ day of_______________ Place : Date : Notary public

  • 11

    (प्रारूप-7)

    नोटराइज् ड शपथ-पत्र

    ( रूपये 100 के नॉन जुडीशशयल स् टाम् प पेपर पर शनष् पाशित )

    मध् य प्रदेश के स् थानीय ननवासी/ मूल ननवासी अभ् यथी के द्वारा ददया जाने वाला शपथ पत्र

    मैं..........................................पुत्र / पुत्री / पत् नी श्री................................................. ............ ननवासी............................मध् यप्रदेश के चिककत् सा / दंत चिककत् सा महाववघालय में स् नातक / स् नातकोत् तर पाठ्रयक्रम में शैक्षणिक सत्र ....................... में प्रवेश हेतु अभ् यथी हंू। मैंने मध् यप्रदेश शासन चिककत् सा शशक्षा ववभाग के मध् यप्रदेश चिककत् सा शशक्षा प्रवेश ननयम 2018 एवं संशोधन जून 2019 को भलीभांनत पढ़कर समझ शलया है। मैं शपथ पूववक यह कथन करता / करती हंू कक मैनें अन् यत्र राज् य से स् थानीय ननवासी / मूल ननवासी प्रमाि पत्र प्राप् त नहीं ककया हैA एव ंमैने अन् य ककसी राज् य से स् थानीय ननवासी /मूल ननवासी होने का लाभ प्राप् त नहीं ककया है । मैनें यह भली भांनत समझ शलया है कक मेरे द्वारा दी गयी जानकारी गलत पाये जाने पर मेरा प्रवेश ननरस् त कर ददया जायेगा। नोट :-अभ् यथी के व् यस् क न होने पर शपथपत्र पर हस् ताक्षर अभ् यथी के अववभावक द्वारा ककय े जायेंगे ।

    हस् ताक्षर अभ् यथी/अववभावक

    नाम- ........................... पता- .............................. ददनांक- ..........................

  • 12

    QksVks

    izk:i&8

    ¼vuqlwph&3&11 (i) (ii) Lukrd ikB;dze gsrq½

    ¼fpfdRlk@nar fpfdRlk egkfo|ky; esa LVsV dksVk vFkok vkWy bf.M;k dksVs ls Lukrd ikB;dze esa

    izosf'kr vH;FkhZ ds fy;s½ ca/k&i=

    lE;d :Ik ls LVkafir ¼ca/k i= dh jkf'k dk 0-5 izfr'kr½

    1& eSa] --------------------------------------------------------------------- iq=@iq=h@iRuh Jh ----------------------------------------------------------

    fuoklh --------------------------------------------- e/;izns'k ds fpfdRlk @nar fpfdRlk egkfo|ky; esa

    Lukrd ikB~;dze esa ’kS{kf.kd l=---------- esa izos'k gsrq vH;FkhZ gwa A

    2& eSus e/;izns'k 'kklu fpfdRlk f'k{kk foHkkx ds e/; izns’k fpfdRlk f’k{kk izos’k fu;e 2018

    ,oa la’kks/ku twu 2019 dks HkyhHkkafr i fy;k gS A

    3& eSa ,rn~}kjk ;g ca/k i= fuEu'krksZ ij fu"ikfnr djrh@djrk gwa fd %&

    i½ lhV fyfoax ckW.M&

    v eSa fpfdRlk@ nar fpfdRlk Lukrd ikB~;dze esa izos'k izkIr djus ds mijkar v/;;ujr

    jgdj ikB;dze iw.kZ d:axk@d:axh A

    c ;g fd] esjs }kjk jkT; Lrjh; dkmaflfyax ds funsZ'kksa esa fofufnZ"V le; lhek ds i'pkr~

    ,oa ikB;dze iw.kZ gksus ls iwoZ fdlh Hkh ifjfLFkfr esa lhV ls R;kxi= fn, tkus vFkok esjk

    fu"dklu fd;s tkus dh fLFkfr esa] eSa lacaf/kr 'kkldh; fpfdRlk@’kkldh; nar fpfdRlk

    egkfo|ky; dh Lo'kklh lfefr dks lhV fyfoax ckaM jkf'k :0 30]00]000@&¼ :0 rhl

    yk[k½ Hkqxrku djus dk opu nsrk gWaw @nsrh gWwa vFkok futh fpfdRlk @nar fpfdRlk

    egkfo|ky; esa izosf'kr lhV ls R;kxi= fn;s tkus ij lacaf/kr laLFkk esa lEiw.kZ vof/k dk

    ’kS{kf.kd 'kqYd 'kklu dks ns; gksxkA

    ii½ xzkeh.k lsok ckW.M&

    v& eSa fpfdRlk Lukrd ikB~;dze iw.kZ djus ds mijkar 'kklu }kjk fufnZ"V LFkkuksa ij fofgr

    vof/k rd vfuok;Z :i ls fpfdRlk lsok iznku d:axh@d:axk A

    c& fofgr vof/k tks fd 'kkldh;@futh Lukrd ikB~;dze esa izos’k ysus ij ,d o"kZ 'kklu

    }kjk fufnZ"V LFkku ij lsok,a u nsus dh fLFkfr esa eSa 'kklu dks :0 10 yk[k ¼vukjf{kr oxZ

    gsrq ½ :0 5 yk[k ¼vkjf{kr oxZ gsrq ½ Hkqxrku djus dk opu nsrh@nsrk gwaA

  • 13

    l& vU; fiNM+k oxZ ds vH;FkhZ }kjk Nk=o`fRr ;kstuk dk ykHk ysus dh fLFkfr esa fofgr vof/k

    tks fd 'kkldh; Lukrd ikB~;dze esa izos’k ysus ij ’kklu }kjk fufnZ"V LFkku ij 2 o"kZ dh

    lsok nsus vFkok :0 10 yk[k Hkqxrku djus dk opu nsrk@nsrh gWwaA ,oa futh fpfdRlk

    Lukrd ikB~;dze esa izos’k ysus ij 5 o"kZ dh lsok nsus vFkok :0 25 yk[k Hkqxrku djus dk

    opu nsrk@nsrh gWwaA futh fpfdRlk egkfo?kky; esa izos'k gksus ij ckWM dk fu"iknu

    lapkyd fpfdRlk lsok ds uke ls gksxkA

    vFkok

    fofgr vof/k tks fd eq[;ea=h es/kkoh fon;kFkhZ ;kstuk@eq[; ea=h tudY;k.k

    ;kstuk dk ykHk 'kkldh; Lukrd ikB~;dze esa izos’k ysus ij ’kklu }kjk fufnZ"V LFkku ij

    2 o"kZ dh lsok nsus vFkok :0 10 yk[k Hkqxrku djus dk opu nsrk@nsrh gWwaA ,oa futh

    fpfdRlk Lukrd ikB~;dze esa izos’k ysus ij 5 o"kZ dh lsok nsus vFkok :0 25 yk[k Hkqxrku

    djus dk opu nsrk@nsrh gWwaA futh fpfdRlk egkfo?kky; esa izos'k gksus ij ckWM dk

    fu"iknu lapkyd fpfdRlk lsok ds uke ls gksxkA

    gLrk{kj vkosnd

    xokg %&

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