Common Application Form-2014-15 - tnhealth.org

Application No :

ADMISSION TO PARAMEDICAL COURSE 2014-2015 SESSION
COMMON APPLICATION FORM

SELECTION COMMITTEE, DIRECTORATE OF MEDICAL EDUCATION

RANDOM NUMBER : A.R. No.

(To be assigned by the Selection Committee )

1. +2 Examination/ Equivalent REGISTER NUMBER YEAR MONTH
Register Number, Year and Month

2. Name in Block Letters (Initial at the end) : SPACE FOR
............................................................... PHOTOGRAPH WITH

3. Address for Communication : NAME AND DATE
………………………………………… ( TO BE ATTESTED
…………………………………………
BY GRADE A / B
OFFICERS OF
CENTRAL / STATE
GOVERNMENTS)

…………………………………………

PIN CODE ..…………………………. 5. Sex : (Encircle a code)
MALE FEMALE
Land line Phone No :………………………….. 12
Mobile No. ………………………………………….
6. Nationality : (Encircle a code)
4. Name of Parent / Guardian : INDIAN OTHERS
12
………………………………………….

7. Nativity : 7 a. Details of Education: (Encircle the code which is applicable)
(Encircle a code)
Studied from VIII Std Studied from VIII Std to
TN Others to + 2 in Tamil Nadu + 2 in Other State
12
1 2

7 b. If you have completed your plus 2/ equivalent schooling in Tamil Nadu encircle a code:

Government Govt.Aided Corporation Municipality KVS CBSE Pvt.School Others(Specify)

1 23 4 56 7 8
STATE
8. School(s) of study (Evidence to be produced from the schools studied):

Sl. STANDARD STUDIED YEAR OF NAME & ADDRESS OF SCHOOL * DISTRICT
No. PASSING WITH CODE

1. VIII STD

2. IX STD

3. X STD

4. X I STD

5. XII STD/EQUIVALENT

* Refer Annexure XV for District Code 1

9. Date of Birth : 10. Community ( Encircle a code )

DATE MONTH YEAR OC BC BCM MBC/DC SC SCA ST
5
1 2 2A 3 4 4A

11. Name of the Caste : ……………………………………..

12. Caste Code :

Refer List of Communities ( For “OC” use code 500 )

13. Qualifying Examination : (Encircle a code ) 13 a. Particulars of passing the Qualifying
Examination :

HSE SSCE/CBSE ISCE OTHERS DETAILS 1st Attempt 2nd Attempt 3rd Attempt
12 34
REG NO

MONTH &
YEAR

14. Religion with code :

15a. Marks obtained in select Science subjects in the Qualifying Examination in the First Attempt only:

SUBJECT MAXIMUM MARKS PERCENTAGE WEIGHTED TOTAL METHOD OF
MARKS OBTAINED OF MARKS MARKS CALCULATION
PHYSICS Y1=
Y Y= Y 1 + Y 2
CHEMISTRY Y2= 2
BIOLOGY X=
BOTANY XX
Z1=
ZOOLOGY Z Z= Z 1 + Z 2
MATHEMATICS Z2= 2
TOTALMARKS W=
W= W
(X+Y)or(Z+Y)or(W+Y)

SUBJECT MAXIMUM MARKS
15.b Marks obtained in the Fourth Optional Subject : MARKS OBTAINED

15c. Marks obtained in English MAXIMUM MARKS
MARKS OBTAINED

YES NO

16.a.If claiming for Special Categories, have you applied
in the Form prescribed for Special Category ( Please Tick )

2

b. If Yes, specify the Special Category with code numbers S.No Code No Special Category
(Maximum of three special categories only permissible) I
II

17 a. Educational status of the family (if admitted will you be the YES NO

First Graduate in the Family ?) (Refer Annexure XV a & b) (Please Tick):

b. Has your brother/ sister availed first YES NO
graduate fee concession for studying professional courses
( Please Tick )

18. Medium of Instruction : ( Encircle a code ) ENGLISH TAMIL OTHERS
19. Mother Tongue with code : 12 3

20. Occupation of Parent / Guardian ( Encircle a code) :

STATE CENTRAL PROFESSIONAL INDUSTRY BUSINESS AGRI- PRIVATE SMALL OTHERS
GOVT GOVT
CULTURE ORGANISATION TRADE

12 3 4 56 7 89

21. Average monthly income of Parent/ Guardian : ( Encircle a code ):

½ 3000 3001-5000 5001-8000 8001-12000 12001-17000 17001- 21000 ¾ 21000

12 345 6 7

22. Civic status of your Native place ( Encircle a code ): OTHERS
6
CORPORATION MUNICIPALITY TOWNSHIP TOWN VILLAGE
1 2 3 PANCHAYAT PANCHAYAT

4 5

23. Civic status of your School place ( Encircle a code ):

CORPORATION MUNICIPALITY TOWNSHIP TOWN VILLAGE OTHERS
1 2 3 PANCHAYAT PANCHAYAT 6

4 5

24. District Code (as given in the Prospectus): NATIVE DISTRICT DISTRICT CODE IN WHICH
XII / EQUIVALENT STUDIED
(As entered in column 8 under Si No. 5)

Signature of Parent / Guardian Signature of Candidate
Date : Date :

3

DECLARATION BY THE APPLICANT & PARENT

I ………………………………………(Name in Full & in Block Letters) Son/ Daughter /
Ward of ………………………………….. an applicant for Paramedical course 2014-2015 session
hereby solemnly declare that I have not claimed Dual Nativity in this regard and I belong to
………………………...(Community) and subcaste ……………………..I also declare that the
information and the statements given in the application, OMR sheet and enclosures are true, correct
& complete. I further declare that if it is found otherwise, I will be liable to forfeit the seat and / or be
removed from the rolls of the Institution at whatever stage of study, I may be, besides making me
liable for criminal prosecution.

I further declare that I have not claimed the marks obtained in HSE/ equivalent examination
under improvement scheme for seeking admission to Paramedical course 2014-2015 session.

I …………………………………………….(Name in Full & in Block Letters) Father/ Mother /
Guardian of ………………………………….. an applicant for Paramedical course 2014-2015 session
hereby solemnly declare that I am fully aware of the above declaration & the particulars furnished are
correct. I declare that if it is found otherwise my ward will be liable to forfeit the seat and also be liable
for criminal prosecution.

Signature of the Parent/ Guardian Signature of the Candidate

Place :
Date :

4

ADMISSION TO PARAMEDICAL COURSES 2014 ‐ 2015 SESSION
SCRUTINY FORM

1. Details of Qualifying Exam INSTRUCTIONS TO FILL UP SCRUTINY FORM
Registration 
Number 1. To be filled by the candidates as per the entries made in the          
.    
Passing  Passing   
Month Year application form and returned
2.  Use only Blue color Ball Point Pen for ticking and writing
3.  Put Tick mark(9) in the correct Gray color boxes 

4.  Write inside the white box, wherever writing is required

2. NAME
3. ADDRESS

Paste here firmly your 
recent Photography         

4cm x 5cm

Pincode :

5. Sex Mobile : 6. Nationality 1. Indian 2. Others 7.Nativity 1. TN 2. Others
1. M 2. F

7a. Details of  Education 1 2 7b. Have completed your  +2/      2 345678
   equalent schooling in TN, if Yes 1

.

9. Date  // 11.Caste 
of Birth Code
1. OC 2. BC 2A. BCM . MBC
10. Community 4. SC 4A. SCA 5. ST 13a. Passed all the Subjects of the Qualifying 
Examination in  Attempts No.

13. Qualifying          1.HSC 2.SSCE/  3. ISCE 4.OTHERS 14. Religion
     Examination CBSE Zoology MATHS
.

15.Marks in Subjects (As Entered in Application Form) Fourth Option Subject

Subject Physics Chemistry Biology Botony ENGLISH Subject Marks

Maximum Marks

Marks Obtained

16a.Special    1. Yes 2. No 17a. First  Graduate   in  1. Yes 2. No 18. Medium  2. Tamil 3.Others
     Category Family of  1. English
.
Instruction

16B.If Yes?  17b. Has your brother/ sister  1. Yes 2. No 19. Mother Tongue
1. Children of Ex‐ Servicemen availed first graduate fee 
2. Physically Disabled concession for studying 
professional courses

21. Monthly                     22. Native  23. School   24.  Native  School 
20. Occupation of       Income of                   Civic  Place Disctrict  District District
the parent Status Place
.  Code

    Parent/ Gaurdian

. 

I sincerely affirm that the information furnished above are true.

Station : Signature of the Candidate with in the box
Place    :

A.R. No.
(For Office use only)

SPECIAL CATEGORY FORM FOR PARAMEDICAL COURSES

2014-15 SESSION

Code No. Category of Special Reservation
01 SONS & DAUGHTERS OF EX-SERVICEMEN
02 ORTHOPAEDICALLY PHYSICALLY DISABLED

1. Application No

(As printed in the Prospectus)

2. Name of the Candidate with .................................................................................

Address .................................................................................

.................................................................................

.................................................................................

.................................................................................

PIN Code .............................................

Telephone No : ................................................................ Mobile No. ............................................

3. Special Category applied for (Tick the relevant Box)

Code 01 Son / Daughter of
Ex-Servicemen Code 02

Orthopaedically Physically Disabled

4. Details of DD enclosed

DD No. DATE AMOUNT Details of Bank

5. Special Category Certificates enclosed Yes No
12

Signature of the Candidate

(For Instructions see overleaf)

Instructions

1. The Special Category form is to be sent along with the application in the same cover.

2. Put 9 in the relevant box in the outer cover.

3. Candidate should enclose a DD for 100/- drawn in favour of the Secretary,
Selection Committee, Kilpauk payable at Chennai. The Name of the Candidate,
Application No. & Address should be written on the reverse of the DD.

4. Candidates should enclose an additional self addressed envelope(s)
(24x12 cms) to send the special reservation counselling call letter(s).

5. Candidates should enclose relevant certificates obtained from the Competent
Authority.

6. Application without a DD for 100/- and without the relevant certificates will
be summarily rejected without intimation to the candidate.

Table showing the Code No. and the Special Category

Code No. Category
01 SONS & DAUGHTERS OF EX-SERVICEMEN
02 ORTHOPAEDICALLY PHYSICALLY DISABLED

ko¡fhÔ®fŸ

DO NOT FOLD APPLICATION FORM FOR ADMISSION TO

PARAMEDICAL COURSES IN

GOVERNMENT / SELF FINANCING COLLEGES IN TAMILNADU 2014-2015 SESSION

(B.Pharm. / B.Sc. Nursing / B.P.T. / B.A.S.L.P / B.Sc. in Radiology &
Imaging Technology / B.Sc. Radio Therapy Technology /
B.Sc. Cardio - Pulmonary Perfusion Technology / B.O.T.

+2 EXAM REGISTRATION NUMBER YEAR OF PASSING +2 EXAM

COMMUNITY OC BC BCM M.B.C/D.C SC SCA ST
(ENCIRCLE A CODE)
1 2 2A 3 4 4A 5
SPECIAL CATEGORY
YES NO Application No.

(Put 3)

From :(Candidate’s Mailing Address) To
The Secretary,
............................................................... Selection Committee,
............................................................... No. 162, Periyar E.V.R. High Road,
............................................................... Kilpauk, Chennai - 600 010.
...............................................................
...............................................................
PINCODE

Note : 1. Candidates seeking admission under special categories have to submit the Special Category form along with the General Category Application in

the same Cover. Otherwise they will not be considered under Special Category.
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xnu ciwÆš rk®¥ã¡fî«. m›thW mD¥g¥glÉšiybaÅš mt® áw¥ò ãÇɉF gÇÓÈ¡f¥glkh£lh®.

SELECTION COMMITTEE
DIRECTORATE OF MEDICAL EDUCATION

CHENNAI 600 010
PARAMEDICAL COURSES 2014 - 2015

CHECK LIST

S. No. ITEM
1 PROSPECTUS
2 COMMON APPLICATION FORM
3 LARGE SIZE COVER FOR DESPATCH OF
APPLICATION BY THE CANDIDATE
4 TWO ENVELOPES (TO BE SELF ADDRESSED
AND SUBMITTED ALONG WITH APPLICATION)
5 SPECIAL CATEGORY FORM
6 OMR SHEET

Note : Candidates are requested to verify whether all
enclosures are available and bear the same serial
number which will be unique for each application
as per checklist.

1