Notice
Students admitted at B.J. Medical College in academic year
2019-20 have to report First Floor, Auditorium on 01-08-2019
at 8:00 am. Hostel allotment and other administrative process
will be done on same day. Students have to take print of forms
attached below and completely filled form will be accepted on
01-08-2019. Students can pay other than tuition fees online on
the basis of unique ID. List of Unique ID will be kept on website
on 29-07-2019. Date of white coat ceremony will be informed
soon via SMS and website. Student with their Parents can
attend white coat ceremony. Please visit our website
http://www.bjmcabd.edu.in/ regularly for more updates.
How to pay fees online?
Online Payment
Step 1 https://easypay.axisbank.co.in/
Step 2 Click on Educational
Step 3 Search B J Medical
Step 4 Enter your Unique ID e.g. "BJ14UG001"
Step 5 Pay your fees
Offline mode Step 1 Visit axis bank branch near you
Step 2 Ask concern person that you want to
pay fees in Easy pay module
Step 3 Inform your Unique ID e.g.
"BJ14UG001"
Dean
B.J. Medical College,
Ahmedabad
:-
______________
:-
_____________________
:-
______________ __________________________________________
:-
________________________________
_________________________________________
_________________________________________
_________________________________________
:- ___/ /
1) . :-
________________________
2) . :-
________________________
,
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DETAILS OF STUDENTS
1
FULL
NAME OF STUDENT
2
NAME OF GRAND FATHER
3
NEET ROLL NO
4
AIQ MERIT NO.
5
HSC SEAT NO.
6
HSC PASSING YEAR
7
GENDER (M/F)
8
PHYSICALLY HANDICAPPED
YES / NO
9
DATE OF BIRTH
10
BLOOD GROUP
11
CANDIDATE
CATEGORY
12
ADMITED CATEGORY
13
MARKS DETAIL
S
OBTAINED
OUT OF
PERCENTAGE
PCB (THEORY ONLY) (12
TH
)
ENGLISH (12
TH
)
NEET
-
2018
14
ADMISSION DATE
15
FULL RESIDENTIAL ADRESS
PINCODE
16
MOBILE NO. 1.
2.
3.
PARENT’ S SIGNATURE STUDENT’S SIGNATURE
DETAILS OF PARENTS/GUARDIAN
1
FULL NAME OF FATHER
2
PERMANENT ADDRESS
3
MOBILE NO.
4
LANDLINE NO
5
EMAIL ID.
6
LOCAL GUARDIAN’S NAME
7
LOCAL GUARDIAN’S
ADDRESS
8
LOCAL GUARDIAN’S
MOBILE NO
PARENT’ S SIGNATURE STUDENT’S SIGNATURE
MEDICAL FITNESS CERTIFICATE
MEDICAL CERTIFICATE OF EXAMINATION OFA CANDIDATE FOR
ADMISSION TO
MEDICAL & PARAMEDICAL COURCES
I hereby certify that I have examined Shri / Kum / Smt………………………………………………………
………………a candidate for admission to the Medical / Paramedical courses and cannot discover
that he /she has any disease, constitutional weakness or bodily infirmity except………………………………
………………………………………………………………………………………………………………
I do not consider this a disqualification for admission to the Medical / Paramedical courses.
His / Her age, according to his / her own statement, is .............................years and appearance years.
Marks of Identification:
Impression of left thumb (1) Signature
(2) Full Name
(3)
Qualification (Minimum M.B.B.S.)
Date: / /201 (4) Registration No.
UNDER TAKING
“I
here by agree to conform to the rules and regulations at present in force or that may hereafter be
made for governance of Medical and Paramedical courses and I undertake that during such course,
I will do nothing either inside or outside the College that will interfere with the orderly governance and
discipline. I am also
aware
that ragging is banned and if found guilty, I shall be liable for cancellation
of admission and punishment
as per
rules. ”
Date:
Place:
Signature of the Candidate
Signature of the Parent / Guardian
ANNEXURE I, Part I
UNDERTAKING BY THE CANDIDATE / STUDENT
1. I, _________________________________________________________
S/o. D/o. of Mr./Mrs./Ms. _____________________________________________have carefully read
and fully understood the law prohibiting ragging and the directions of the Supreme Court and the
Central / State Government in this regard.
2. I have read the copy of the MCI Regulations on Curbing the Menace of Ragging in Higher
Educational Institutions, 2009.
3. I hereby undertake that-
• I will not indulge in any behavior or act that may come under the definition of ragging,
• I will not participate in or abet or propagate ragging in any form,
• I will not hurt anyone physically or psychologically or cause any other harm.
I hereby agree that if found guilty of any aspect of ragging, I may be punished as per the provisions
of the MCI Regulations mentioned above and / or as per the law in force.
Signed this _____________day of ______________month of _____________year.
Signature
Address: ___________________________________
____________________________________
____________________________________
Name :
1) Witness :
2) Witness :
ANNEXURE I, Part II
UNDERTAKING BY PARENT/ GUARDIAN
1. I, _________________________________________________________
F/o. M/o. of G/o. _________________________________________________have carefully read and
fully understood the law prohibiting ragging and the directions of the Honorable Supreme Court and
the Central / State Government in this regard as well as the MCI Regulations on Curbing the Menace
of Ragging in Higher Educational Institutions, 2009.
2. I assure you that my son / daughter / ward will not indulge in any act of ragging.
3. I hereby agree that if he / she is found guilty of any aspect of ragging, he / she may be punished as per
the provisions of the MCI Regulations mentioned above and / or as per the law in force.
Signed this _____________day of ______________month of _____________year.
Signature
Address: ___________________________________
____________________________________
____________________________________
Name :
1) Witness :
2) Witness :
B. J. MEDICAL COLLEGE, AHMEDABAD for U.G. Students
Year of Admission __________________
Valid Up to ______________
FILLED IN BLOCK CAPITALS
FULL NAME (As per Mark sheet):-
_______________________________________________________
DATE OF ADMISSION:-_______________________________________________________________
DATE OF BIRTH (As per L.C./Documents):-________________________________________________
BLOOD GROUP:-____________________ LOCALITE/HOSTELITE (ROOM NO):-______________
LOCAL ADDRESS:-___________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
PHONE NO:-___________________________________ Email ID (Student):- _____________________
MOBILE NO:-__________________________________
PERMEANENT ADDRESS: - ___________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
PHONE NO :- (Residence): - ___________________________________________
MOBILE NO :- (Parents/Guardian):-____________________________________
Email ID: - (Parents/Guardian):- _______________________________________
Signature of Students
FOR OFFICE USE ONLY
Remarks: -
Signature of In-charge
Dean
B. J. Medical College, Ahmedabad.
PHOTO
B.J.MEDICAL COLLEGE, AHMEDABAD
(Application Form for the Library Membership)
To,
The Dean,
B.J.Medical College, Ahmedabad-380016
Sir,
I intend to become a member of our library as UG/Pg/Faculty. I have read the rules &
regulation printed on the back of this form & I agree to abide with them.
PARTICULARS
1. Full Name :______________________________________________________________________
In Block Letters Surname First Name Father’s Name
2. Father’s (Gardian’s) Name:_________________________________________________________
Father’s (Gardian’s) Occupation: _____________Official Contact No._____________________
3. Permant Address:________________________________________________________________
(Residential) ___________________________________________________________________
4. Hostel OR Present Address:
_______________________________________________________________________________
5. Designation: U.G/P.G/Faculty Class & Term if U.G.______________
6. Duration
Yours’ Faithfully,
( )
UNDERTAKING by two staff members / Students of B.J.M.C. Ahmedabad.
1. Mr./Dr._____________________________________________Designation______________
2. Mr./Dr._____________________________________________Designation______________
I hereby undertaking to pay amount that may be found recoverable from
Mr/Dr_____________________________________due to late fee, loss of books / journals ets.
Immediately on receipt of the intimation from the authorities concerned.
Signature of Staff / Student Address
1)
2)
The above facts have been verified from the office records.
Recommended / Not recommended for library membership
HOD Director Dean
(applicable incase of Faculty) (Postgraduate Studies) (B.J.M.C)
B.J.Medical College,Ahmedabad
Application for Hostel Accommodation.
To,
The chief Warden
B.J.Medical College,Ahmedabad.
Sir.
I hereby Apply for Hostel Accommodation accordingly Submit following Bio-data along
with necessary documents for it.
1. Name of Applicant in Full :--------------------------------------------------------------------------------------
-
2. Father’s Name in full :--------------------------------------------------------------------------------------
-
3. Father’s Occupation :---------------------------------------------------------------------------------------
4. Permanent residential Address :----------------------------------------------------------------------------
------ -------------------------------------------------------------------------------------------------------------------
----------
5. Phone No. : (Self):------------------------------------------------(Father/Mother) :------------------------
-
6. Local Address if guardian/relative with Name :------------------------------------------------------------
-
7. Details of Xll/CEB Result :-----------------------------------------------------------------------------
Marks obtained : ---------------------------------------Aggregate :----------------------------------
Science Subject---------------------------------------------
Maximum Marks :-------------------------------Theory : ---------------------------Practical:----------------
-
HSC Seat No No.--------------------------------Guj Cet Seat No.----------------------------------
Year of passing :-------------------------------------
8. Calegory :---------------------------------------------
9. Documents Enclose (Attested Gopies only)
A: 1. Xll/CEB Mark sheet 2. Guj Cet Mark sheet
B. School Leaving Certificate
C.Caste Certificate
D.Passport Size Photo (Two)
E.Address Proof
F.Admission order of MBBS Coures & Hostel
10. Declaration: I shall abide by the rules regulations of Hostel Accommodations
Place: --------------------------- Signature of Candidate:--------------------------------------------
Date: ---------------------------- Signature of Father/Mother/Guardian----------------------------
--------------------------------------------------------------------------------------------------------------------------
Affix passport
Size photograph of
Candidate
(FOR OFFICE USE ONLY)
1. Admission Granted/Not Granted:
2. Hostel Block:--------------Room No. :--------------------------------
3. Hostel Fee Rs. 1200/- Receipt No. :--------------------------------
4. Hostel Deposited Rs. 1000/- Receipt No :-----------------------------Date : ------------------------------
-
DECLARTION BY THE CANDIDATE
I hereby declare that the particulars furnished in the application form are correcr to
Best of my Knowledge and understanding. I have verified my eligibility to apply against the
Category to which I am entitled. In case of incomplete information, I understand that my
Candidature is likely to be cancelled and in case any information furnished in the form is
Found to be incorrect or false , at any stage, my candidature/admission shall be cancelled
Without prior notice, l further declare that l shall abide by the provisions of the Act and Ru
Made there under or any directions / instructions of the Admission Committee for
Professionl Medical Education Courses, I am also aware that ragging is banned and if fou
Guilty. I shall be liable for cancellation of admission and punishment as per rules.
Date :-------------------------- Signature of Candidate:---------------------------
-----
Place :-------------------------- Signature of Father/Mother/--------------------
------
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DEPARTMENT OF
ANATOMY B. J. MEDICAL
COLLEGE, AHMEDABAD
YEAR OF ADMISSION SEPTEMBER –2019
ROLL NO:
DATE OF ADMISSION:
NAME:
DATE OF BIRTH:
BLOOD GROUP: LOCALITE / HOSTELITE:
LOCAL ADDRESS: ROOM NO. :
Phone No.:
Mobile No.:
PERMANENT ADDRESS:
Phone No. (Residence):
Mobile No.(parents/guardian):
Signature of student
FOR OFFICE USE ONLY
COUNSELLING Signature of student Signature of In-charge
Stick passport
size
Photograph
here
1
Note: The duly executed Bond and Solvency Certificate are to be submitted at the time of joining the
Government Medical college to the Dean of respective college to which the candidate has been
admitted in the academic year 2019-2020
BOND FOR STUDENTS PROVISIONALLY ADMITTED TO M.B.B.S. COURSE
(Non withdrawable)
KNOW ALL MEN BY THESE PRESENT THAT WE ..................................................................... son /
daughter of Shri .................................................................. (hereinafter called “The student” in case he / she
has completed 18 year of age) and “father or natural guardian of the student”, (in case he/she is a minor) which
expression shall unless excluded by or repugnant to the context include his / her heirs administrators and
assigns and ....................................... son / daughter / wife of Shri .................................................................
hereinafter called “the Surety” which expression shall unless excluded by or repugnant to the context include his
/ her heirs, administrators and assigns bind ourselves jointly and severally to pay to the Governor of Gujarat
(hereinafter called” the Government”) on demand and without demur a sum of Rs. 5,00,000(Rs. Five lakh only)
or if payment is to be made in a “country other than that of India” the equivalent of the said sum in the currency
of that country converted at the official rate of exchange between that country and India.
Dated this ..................................................................... day of .................................... Two thousand.
WHEREAS the Government has decided to prescribe a condition for admission to Government Medical
college for the M. B. B. S. degree course (hereinafter referred to” the Said course”) that every student so
admitted shall complete the said course from that college or from any other college in the state and that on such
completion he / she shall if so required by the Government to serve in any of the rural areas of the state for a
minimum period of 3 years including one year service in any of the tribal areas of the State on such
remuneration as may be prescribed thereof and shall furnish a suitable bond for the due performance of the said
conditions.
AND WHEREAS the student who had applied for admission for the said course in ................................
......................... College, (hereinafter referred to us “the said College”) has been admitted for the said course.
NOW the condition of the above written obligations is that if the student shall:
(1) Deligently prosecute and complete the said course at the said college or any other Medical College in the
State and pass the prescribed university examination for the said course, and
(2) within a period of 30 days from the date of his/her completing the period of internships or rotating
housemanship give to the Government by registered post notice in writing intimating the completion of his/her period
of internship or housemanship provided however that if the student is desirous of continuing post-graduate studies.
Such notice shall expressly specify such desire and request for permission of the Government to continue such post
graduate studies and it shall be open to the Government in its absolute discretion to refuse such permission or to
grant it subject to the condition that the student shall within one month from the completion of post-graduate course
give a like notice to the Government: and
(3) When called upon by the Government at any time within a period of six months from the receipt of the
notice from the student as aforesaid join the state Services and serve in any of the rural areas of the state for a
minimum period of three years including one year service in any of the tribal areas of the State at such remuneration
as may be prescribed thereof and in the event of the student not being so called upon by the Government to join the
State Services and serve them for the aggregate period of three years in any of the rural areas of the State including
one year service in any of the tribal areas of the State and during the period which the student is required to serve
under the provisions of this bond faithfully discharge the duties assigned to him/her by the Government or his/her
other superiors with utmost deligence and efficiency and shall observe the rules for time being inforce regulating the
conduct of persons so serving.
Then the above written bond shall become void otherwise the same shall remain in full force and virtue.
And in the event of student committing a breach of any of the above terms and conditions the whole of the
amount of Rs.5,00,000 (Rupees Five lakh only) As per Government of Gujarat Health & Family Welfare Department
Gandhinagar resolution dated 28-06-2013 & 01-07-2013 No. MCG/1013/SFS-54/J or such lesser sum as the
Government may in its absolute discretion decide, shall become payable jointly, and severally by the student or the
father / natural guardian of the student in case of minor student and the above surety ............................................ (Full
name of the Surety ) ....................................................... .................................. forthwith and the Government may
without prejudice to any other rights and remedies of the Government recover the same from the student or the
father/natural guardian of the student in case of a minor student and the above surety.
................................................................................................................................................................................
.................................................................................................................................................................................
(Full name of the surety)
And upon making of such payment the above written obligation shall be void and of no effect, otherwise it shall be and
remain in full force and virtue ;
2
Provided always and it is hereby agreed and declared that the decision of the Government as whether the said
student has or has not performed and observed any of the obligations and conditions herein before recited and
the amount of compensation payable in this behalf shall be final and binding on the parties hereto.
Provided further that the liability of the surety here under shall not be impaired or discharged by reasons
of time being granted or any forbearance, act of omission of the Government (with or without the knowledge or
consent of the surety) in aspect of or in relation to the several obligations and conditions to be performed or
discharged by the student provided that the government may without prejudice to any other rights or remedies of
the Government to recover such amounts due here under from the student or father/ natural guardian of a minor
student or from the surety as an arrears of land revenue and provided further that this bond shall in all respect
be governed by the laws of India. The expenses of stamp duty on the bond if any, shall be borne by the
Government.
I witness whereof the said student or father/ natural guardian of the student in case he is a minor and the
said surety have put their respective hands the day and the year herein above written.
Signed and delivered by the within named student ..................................................................
or father / natural guardian of student in case (Signature of student or father/ natural
he/she is a minor in the presence of - guardian of student in case he / she is a minor)
1. Signature :
Full Name:
2. Signature:
Full Name:
Signed and delivered by the within (Signature with full address of surety.)
named surety in the presence of -
1. Signature :
Full Name:
2. Signature:
Full Name:
Accepted by .................................................. granted on behalf of the Governor of Gujarat.
3
CERTIFICATE OF SOLVENCY
This is to certify that ...................................................................................................................................
(full name with address of surety)
who as stood surety to ................................................................................................................................
(full name and address of student)
Candidate seeking admission to the M.B.B.S. course is solvent to the extent of the amount stipulated in the bond
executed by the student or father / natural guardian of the student in case he/she is a minor in respect of the
above mentioned admission.
This certificate is issued on the strength of the attached solvency certificate dated ..............................
.................................................... (in the form No. R.S.B., 2g.) produced by the said surety.
Date : (Signature of the Collector/ Deputy
Collector/Mamlatdar)
Place :
Designation.
Seal
4
FORM No. R.S.B. 2g.
FORM OF SOLVENCY CERTIFICATE
(No Solvency certificate more than a month old will be accepted)
As per Government of Gujarat, Health & Family Welfare Department, Gandhinagar resolution
Dated 28-06-2013 & 01-07-2013 No. MCG/1013/SFS-54/J
[Property’s Market Value should be at least 5 times of Bond amount]
1. Name :
2. Father’s Name :
3. Residence :
4. Age.:
5. Occupation :
6. Purpose for which required :
7. Whether the person certified possesses movable, or immovable property or both :
8. If movable estimated value and grounds for belief :
9. If immovable :
A. If in lands -
a. Areas and where situated,
b. Assessment.
c. Market value.
d. Whether it is in the sole ownership of the person certified and, if not the extent of his share, the
names of to other share, and whether they have any objections extent to urge,
e. Whether it is a Joint Hindu Family Property and if so the extent of his share the names of other
coparceners and whether they have any objection to urge.
B. If in house :
a. Where situated :
b. Market value :
c. Whether it is in the sole ownership of the person certified, if not, the extent of his share, the names
of other shares’, and whether they have any objections to urge,
d. Whether it is a Joint Hindu Family Property and, if so, the extent of his share, the names of other.
coparceners and whether they have any objections to urge. Declaration by the person being
certified on solemn affirmation.
1. 2. 3.
I hereby solemnly declare that the property described and the immovable property mentioned above is
unencumbered.
Date: (Signature)
Signature in the presence of :
10. Report of the village officers of the place where the property is situated.
11. Opinion of the certifying officer :
Camp :
Dated: (Signature)
N. B. As regards Nos. 8, and 10, if the particulars required cannot be conveniently entered against them
they should be appended on separate sheets and the signature of the certifying office and note to
that effect made against the number of item concerned.
Name : Father’s Name Incidence : Age-Occupation.
Certifying Officer.
