RAICHUR INSTITUTE OF MEDICAL SCIENCES, RAICHUR
PROFORMA TO BE FILLED IN BY THE CANDIDATES ADMITTED TO PG COURSE
0 Name of the candidate (Capitals)
1
0 Course
2
0 i) Father’s Name
3 ii) Occupation
iii) Annual Income
0 Mother Name
4
0 i) Sex ii) Religion
5 iii) Mother Tongue
0 i) Permanent Address with Pin
6 code
ii) Cell No.
iii) E mail ID
0 Caste and Subcaste
7
0 i) Nationality ii) State.
8 iii) Area (Urban/ Rural)
0 i) NEET Rank No.
9 ii) Percentile
iii) Marks obtained / Maximum
Marks
1 i) Qualifying Exam and Register MBBS Reg. No.
0 No.
ii) Year of passing with date
1 i) University/ Board
1 ii) College (MBBS)
1 Secured Marks/ Maximum Marks
2
1 Date of Admission
3
1 Age & Date of Birth ( DD/ MM/ YYYY)
4
1 Blood Group
5
1 i) Amount paid at the time of Admission
6 ii) Receipt No.
Signature of the
Candidate
RAICHUR INSTITUTE OF MEDICAL SCIENCES, RAICHUR
PROFORMA TO BE FILLED IN BY THE CANDIDATES ADMITTED TO PG COURSE
0 NEET Roll Number
1
0 Course Name
2
0 Date of Birth ( DD/ MM/ YYYY)/Gender
3
0 Name
4
0 Category
5
0 Registration No. MCI/ State Medical
6 Council
0 Registered Council Name
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0 Date of Admission
8
0 Name of the Entrance Exam
9
1 Entrance Exam Percentile/ NEET
0 Percentile
1 Entrance Marks Obtained/ Max. marks
1 (NEET)
1 NEET All India Rank
2
1 NEET State Rank
3
1 State
4
1 Student Category
5
1 Caste Name
6
1 Admitted Category
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1 MBBS Passed Year
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1 MBBS Registration Number
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2 Obtained Marks in MBBS/Maximum Marks
0
2 Category
1
Signature of the
Candidate
Fee Structure
1. Tution Fees
a. Pre Clinical 25,000/-
b. Para Clinical 50,000/-
c. Clinical 1,00,000/-
2. University Fees 13400/-
3. Laboratory Fees 500/-
4. Helinet Internet Fees 1500/-
5. Sports Fees 1000/-
6. Association Fees 1000/-
7. ID Card Fees 300/-
8. Lit. Cultural Activity Fees 1000/-
9. Library Fees 500/-
10. Magazine Fees 500/-
11. Medical Examination Fees 500/-
12. Miscellaneous Fees 4200/-
13. Skill Lab Fees 1000/-
Total Fees
Pre Clinical Subjects 52,900/-
Para Clinical Subject 80,400/-
Clinical Subjects 1,35,400/-
Documents required for admission
1. Admit Card
2. Rank Letter
3. 10th Marks Sheet
4. 12th Marks Sheet
5. MBBS Marks Sheets
6. MBBS Degree Certificate
7. Internship Completion Certificate
8. Attempt Certificate
9. State Medical Council Registration Certificate
10. Aadhar Card
11. Passport Size Photos (5)
12. Bonds in Prescribed Formats.
Should be typed on a stamp paper and should be
notarized along with signature of witness and
parents wherever needed.
13. Income and Caste Certificate
14. Transfer Certificate (From Previous college)
15. Eligibility Certificate (If studied MBBS in other
than Rajiv Gandhi University of Health Sciences,
Karnataka)
16. Physical Handicap Certificate ( If applicable)
17. Two sets of photocopies of all documents.
All the candidates are hereby informed to make soft
copy of all documents individually in pdf format and
label them in sequence. Submit the same at the time
of admission in a pen Drive.
Note: The Bond conditions and Fee Structure may
change as per the Government of Karnataka Rules
and Regulations from time to time.
Annexure 4
Compulsory Rural Service Bond Format for non in-service Candidates
(To be submitted at college at the time of admission)
I, Dr.__________________________________________aged_____ Years
S/o_____________________ Permanent of Resident of
____________________________________________________ at present residing at
____________________________________________________., do hereby swear on oath as follows;
1. That I am admitted to RAICHURINSTITUTE OF MEDICAL
SCIENCES, RAICHURCollege for PG/Broad-specialty/Degree/Diploma
in___________ (mention the subject) under ALL INDIA/ State
quota.
2. I am submitting the bond after reading and fully understanding the
Karnataka Compulsory service by candidates completed Medical course act
2012 and its amendment time to time.
3. I state that I have admitted under non-in-service State quota / All India
quota.
4. I understand that all the candidates (other than the candidates who have
undergone compulsory rural service after award of MBBS degree) who take
admission to PG Medical Degree/Diploma courses and successfully
complete the Post Graduate Degree/ Diploma shall under go one-year
compulsory service in Government hospital in urban area as per Karnataka
Compulsory service training by the candidates completed medical courses
(counseling, allotment, and certification) as per Karnataka Compulsory
Service Act 2012 as amended in time to time and rules there under to the
said act.
5. I am fully aware of the fact that the candidates will be entitled to only
temporary registration till completion of such service. I shall be abide
voluntarily to the said condition.
Signed this day of ___________________________ by the Bounden
Contd..2
-2-
DETAILS OF SURETIES
1. Name : ....................................................................................
S/o, D/O, W/o ……………………………………….
aged …………… years, having Aadhar no..............., PAN No. ........
permanent resident of …………………………………………and
presently residing at ……………………………………..................,
2. Name: ………………………………………………………………..
S/o, D/O, W/o ……………………………………………………….
aged …………… years, having Aadhar no..............., PAN No. ......
permanent resident of …………………………………………and
presently residing at ……………………………………..................,
WITNESS
1.
2.
Bond to be Executed on 200/- Bond Paper
1st Party : Student
2nd Party: Director, Raichur Institute of Medical Sciences, Raichur
Annexure 4-A
UNDERTAKING AS REQUIRED UNDER RULE 15(5)OF THE KARNATAKA
CONDUCT OF ENTRANCE TEST FOR SELECTION AND ADMISSION TO
THE POST-GRADUATE MEDICAL AND DENTAL DEGREE AND
DIPLOMA COURSES RULES, 2006 FOR CLINICAL SUBJECTS IN
MEDICAL / DENTAL COURSES.
(To be executed on a stamp paper of Rs. 200/- duly notarized)
I Dr._______________S/o, _______________aged __ years, having Aadhar
no____________ PAN No. __________________permanent resident of
_____________________________________and presently
residingat_____________________________________________________________
(herein after referred to as BOUNDEN) do hereby swear on oath as follows:-
1) That I am admitted to ‘Government’/‘Government-quota’ seat for ‘All India
quota’/‘State quota’ in RAICHUR INSTITUTE OF MEDICAL
SCIENCES, RAICHUR college for post-graduate medical/dental
degree/diploma in________________(Indicate the subject) during the
centralized counseling for admission to post-graduate courses-2024-25.
2) I am aware of the fact that the Fees for ‘Government’/‘Government-quota’ seat
is highly subsidized, I shall be under an obligation to serve the State of
Karnataka for a minimum period of three years after completion of my post-
graduate course as required under rule 15(5) of the Karnataka Conduct Of
Entrance Test For Selection And Admission To The Post-Graduate Medical
And Dental Degree And Diploma Course Rules, 2006. After reading and fully
understanding the above mentioned Rules, I have opted for the
‘Government’/‘Government-quota’ seat.
3) In compliance with the above Rule 15(5), I hereby furnish the undertaking
voluntarily, with my free will that I shall abide by the condition to serve the
Government of Karnataka for a period of three years after completion of my
post-graduate course in any location decided by the Government of Karnataka,
and that If I fail to comply with undertaking, myself and/or my sureties
mentioned below dohereby bind ourselves and each of us, our and each
of heirs,executors and administrators jointly and severally to pay to the
Governor of Karnataka on demand, we shall pay a penalty of Rs. 50.00 lakh
(RUPEES FIFTY LAKH ONLY) for post-graduate degree/ Rs. 25.00 lakh
(RUPEES TWENTYFIVE LAKH ONLY) for post-graduate diploma to the
Government and only after payment of penalty, I shall collect my original
documents which are in the custody of the Institution.
4) I am enclosing the details of two sureties along with their self- attested
copies of PAN card and Aadhar card.
Signed this day of ___________________________ by the Bounden
Contd..2
-2-
DETAILS OF SURETIES
1. Name : ....................................................................................
S/o, D/O, W/o
……………………………………….
aged …………… years, having Aadhar no..............., PAN No. ........
permanent resident of …………………………………………and
presently residing at ……………………………………..................,
2. Name: ………………………………………………………………..
S/o, D/O, W/o ……………………………………………………….
aged …………… years, having Aadhar no..............., PAN No. ......
permanent resident of …………………………………………and
presently residing at ……………………………………..................,
WITNESS
1.
2.
Bond to be Executed on 200/- Bond Paper
1st Party : Student
2nd Party: Govt. of Karnataka
