Fields marked with * are mandatory

Instructions
1. Documents to be furnished in original at the time of verification of documents along with one set of photocopies should be self attested and a copy of online submitted application form / Receipt 2. जिन विद्यार्थियों ने इस सत्र 2020-2021 में बुंदेलखंड चिकित्सा महाविद्यालय सागर की पैरामेडिकल में किसी भी कोर्स में एडमिशन लिया है वह इस आवेदन एवं प्रवेश प्रक्रिया के पात्र नहीं होंगे।

Applying for Course *

Applied As *

Personal Details
Examination City Center Name 1 *		Examination City Center Name 2*		Examination City Center Name 3*
Applicant's Name*
Father's/Husband's Name*
Mother's Name*
Domicile of MP:*		Category:*		Nationality:*
OBC Creamy Layer *
Have you got caste certificate of caste under the Manjhi Scheduled Tribes like Dhivar, Kahar, Bhoi, Kevt, Mallah, Nishad etc?*
Gender*		Date of Birth(DD/MM/YYYY)*	(In DD/MM/YYYY)	Age as on 31/12/2020	- -(yy-mm-dd)
Marital Status*				Date Of Marriage (In DD/MM/YYYY)
No. of Children		Last child birth date (In DD/MM/YYYY)		Is Your Last Child Born Twins
Are You an Ex Serviceman*
Are You Physically Handicapped ?*
Type Of Physically Handicapped

Educational Qualification

Qualification Specialization Passing Year (In YYYY) University/Board School/Institute Name Obtained Percent (In 00.00 Format) 10th* 10th 12th* Biology Subject* Biology अभयर्थी 12th में जीव विज्ञान विषय का पूर्णांक में से प्राप्तांक अंको का प्रतिशत डाले | Post Graduation* Others * If yes,Registration No. Candidate must be medically fit. They will have to appear before a medical board constituted for this purpose by the medical college?*

In case your University/Institute does not award marks,please convert grades(CGPA) to Percentage marks and fill. * All the Courses are full time. The candidate shall not register for any other degree/diploma along with Paramedical Course. If found guilty, legal action will be taken against him/her

* Write % of marks with two digits after the decimal. The second digit after the decimal should be rounded off. e.g., if Marks is 60%, then write 60.00%. If marks are 68.938% then write 68.94%.

Are You Departmental(Dep.of.Medical Education /Dept.of health & Family Welfare) Permanent Employee?*
Total Experience(yy/mm/dd) -

Experience Details
During the service in BMCSagar, Candidate was terminated or discontinued from his/her Service(Agreement Not Renewed) by the department UNDER National Rural Livelihood Mission?*
Reason	Date(dd/MM/yyyy)
Do you have Minimum 3 years continues working experience for the post of Assistant District Manager / Accountant Under Scheme of Panchayat and Rural Development Department?*
*
Organization Name Field Name Department Type From date (In DD/MM/YYYY) To date (In DD/MM/YYYY) Total experience     YY 0 MM 0     YY 0 MM 0     YY 0 MM 0     YY 0 MM 0     YY 0 MM 0 Total work Experience in Years-Month :- 0 -0

Communication Address
Address*
State*		City/Town*		Pin Code.*
Email id*		Mobile No.*		Phone No.

Permanent Address(Same as Communication Address)
Address*
State*		City/Town*		Pin Code.*
Mobile No.*		Phone No.

Bank Details
Account Number *		Bank Name *
Account Holder Name *		IFSC Code *

Attachment*
Attach Photo with Signature* Upload Image
Click here for photo sign format

Declaration *

मैं एतद् द्वारा घोषणा करता/करती हूंॅ कि आवेदन-पत्र में दी गई समस्त जानकारी एवं संलग्न दस्तावेज पूर्णतः सत्य है। सत्यापन पश्चात् दी गई जानकारी एवं दस्तावेज असत्य पाए जाने पर मेरा प्रवेश निरस्त किया जा सकेगा तथा मेरे खिलाफ वैधानिक कार्यवाही की जा सकेगी। साथ ही इस संस्था में प्रवेश के पश्चात् अन्य किसी संस्था/विश्वविद्यालय में किसी भी पाठ्यक्रम में प्रवेश नहीं लूंगा और ना ही अध्ययन करुंगा और ना ही अन्य संस्था से शासन द्वारा किसी भी प्रकार की आर्थिक सहायता का लाभ प्राप्त करुंगा। यदि मेरे द्वारा ऐसा किया जाता है, तो मेरे खिलाफ वैधानिक कार्यवाही की जा सकती है एवं प्रवेश निरस्त किया जा सकेगा, जिसके लिए मैं स्वयं उत्तरदायी होऊंगा।