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JANARDAN RAI NAGAR RAJASTHAN VIDYAPEETH UNIVERSITY
PRATAP NAGAR UDAIPUR
FACULTY OF MEDICINE
DEPARTMENT OF PHYSIOTHERAPY
Form No. ................
ADMISSION FORM
Passport
Size
Photo
Course : B .P.T./M.P.T. /DANP/DCBR
Seat: Merit/Payment) [to be mark by Candidate (b)]
(to be filled by office )
(Category of
1. Name of the Candidate in English : ----------------------------------------------------------------------
(in capital letters)
Name of the Candidate in Hindi : ----------------------------------------------------------------------
2 Date of Birth : ------------------------------------ Blood Group : -----------------------------
3 Place of Birth :-------------------------- --------- State : ---------------------------------------
4 Nationality :-------------- --------------------- Religion : ----------------------------------
5 Category (SC/ST/PH/OBC/Others/General) :---------------------------------------------------------------
6 Father's name : ---------------------------------------------------------------------------------------------
7. Mother's Name : ---------------------------------------------------------------------------------------------
8 Guardian's Name : ----------------------------------------------------------------------------------------------
(any person other than the parents of the candidate, can become guardian only if the parents
are not alive or are insane.)
9. Occupation of
Father : ----------------------------------------------------------------------------------------------------------
Designation
(If in Service) : ----------------------------------- Deptt.: ------------------------------
Office Address with Phone No. : ----------------------------------------------------------------------------------
(If in business nature of business) ----------------------------------------------------------------------------------
10. Occupation of
Mother : -------------------------------------------------------------------------------------------------------------
Designation (if in service) : -------------------------------- Deptt. : ----------------------------------------
Office Address with Phone No. : -----------------------------------------------------------------------------
anybody of your blood relation studied in any of the college/institution of Janardan Rai Nagar
Rajasthan Vidyapeeth (University) please give details.
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S.No. Name Relation
with
student
Course
Studied
College/
institution
Year of
Leaving
Result
11. Any relatives of the candidate is working/left, with/from Janardan Rai Nagar Rajasthan
Vidyapeeth (University) please indicate:
S.No. Name of employee
Working/
left
Department
Relation with
the candidate
Duration
of
Service
Left on
12. Details of your family members (only blood relatives i.e. Father, Mother, Wife, Husband,
Brother, Sister, Son & Daughter).
S.No. Name of the family
members
Age Relation
with
student
Occupation
(Study/Service)
School /
Colloge /
Deptt.
Designation
13. PERMANENT ADDRESS: POSTAL ADDRESS (for correspondences)
PIN CODE - PIN CODE -
Phone No. - Phone No. -
Mobile No. - Mobile No. -
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14. LOCAL REFERENCE (in case the native place of the candidate is out of Udaipur)
Name & Address:
15. ACADEMIC RECORD: X th - STANDARD
Roll No.: ______________ No. of attempts: _____________
Name of Board: School: Medium:
Year of Passing Subjects Max. Marks Marks obtained Percentage
Total Marks
Percentage
16. ACADEMIC RECORD: XII th (10+2) STANDARD
Roll No.: ______________ No. of attempts: _____________
Name of Board/Uni. School/College: Medium
Year of passing Subjects Max. Marks Marks obtained Percentage
Th. Pr. Th. Pr.
Total Marks
Percentage
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17. Academic Record : B,P.T. (Bachelor of Physiotherapy)
Name of University Name of College Enrollment No.
Year of Passing Year Max. Mark Marks Obtain Percentage
I st Year
TOTAL MARKS
PERCENTAGE
II nd Year
III rd Year
IV th Year
Note:
1. Serial No. 15, 16 must be filled by B.P.T. / DANP/DCBR Candidate.
2. Serial No. 15, 16 &17 must be filled by M.P.T. Candidate.
---------------------------------------
(Signature of Candidate)
CERTIFICATE OF PRINCIPAL OF
SCHOOL/COLLEGE LAST ATTENDED
I, certify that Shri./Smt./Miss……………………………..S/o/D/o………………………...
Shri/Smt ........................................................... of our School/College has passed/
appeared in all the subject of the following examination with particulars noted
against each:-Higher Secondary Examination under Ten plus two (10+2) /
Bachelor of Physiotherapy and has secured marks out of ---------------------marks.
His / Her date of birth as extended in our school / college record is
...................................... He/She bears a good moral character.
Date …………………..
Name & Signature of the Head master/
Headmistress/Principal with seal.
Name:……………………..
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DECLARATION BY THE CANDIDATE
I ..................................................... S/O/D/O,Shri/Smt. . ..................................... a candidate of
…………………………………………………course of the Faculty of Medicine, Janardan Rai
Nagar Rajasthan Vidyapeeth for the session …………….declare that:
1. I have carefully gone through the rules and regulations regarding Admission to the said
course. I find myself eligible for the same and promise to abide by them.
2. I do solemnly affirm that the statement and information furnished by me as above and also
in the enclosures submitted are true. I realize that, if any information furnished there in is
found to be false in material particulars. I shall be liable to criminal prosecution as well as to
forgo my admission and to be removed from the Institute, if already admitted. I shall abide
by the decision of the Janardan Rai Nagar Rajasthan Vidyapeeth (University), Udaipur.
3. I also undertake to pay the Institution dues regularly.
4. I hereby agree, if admitted, to abide by the rules and regulation of the Institute of
University, I undertake that so long as I am a student of the institute I will do nothing either
inside or outside the Institute that will interfere with its orderly working and discipline.
5. If I am found involved in any type of the activity against the declared rules, already
mentioned in the bulletin, my admission may be cancelled at any time without any notice.
6. I also declare that:
(a)
(b)
(c)
(d)
(e)
I have not been convicted of any criminal offence nor have I been released on bail in
connection with a criminal case.
No case of criminal offence or moral turpitude is pending against me in any court of law.
No complaint or FIR has been lodged against me by the University/Principal of constituent
college/school.
I have not resorted to any act of in-discipline during the past year.
I have not been restricted or suspended from any school/college/institution.
Note: (a) to (e) if yes, please give in details in separate sheet.
------------------------------------
Signature of the Candidate
Place : ----------------------
Date : -----------------------
In English : ……………………………….
In Hindi : ………………..…………………
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PARENT'S CERTIFICATE
1 I/We ………………………………… (father) ………………… (mother)…………………………
solemnly affirm that I/We the natural father / mother of Shri. / Kum .................................. and
my/our monthly income is Rs ……...............
OR
GUARDIAN'S CERTIFICATE (If natural father/mother is not alive)
I ............................................................. solemnly affirm that Shri./Kum .......................................
is the son/daughter of Shri..................................................... and I am the guardian of Shri./Kum.
........................................................ as his/her parents have died/become insane. He / She is my
………………………………………..(state relationship).
2 I/We have carefully read all the rules and regulations regarding the admission of my/our
son/ daughter/ward and promise to abide by them.
3 I/We hereby solemnly affirm that the statement and information furnished in my/our son's
daughter's/ward's application as also in the enclosed thereto are true. I/We realize that if
any information furnished therein is found to be false in material particulars, my/our ward
id liable to criminal prosecution and if admitted, to be removed from the institution.
4 I/We undertake the responsibility for his/her conduct and for maintenance of discipline
and shall pay regularly all his/her expenses during his/her stay at the institution.
S No. Name Signature in
English
Signature in
Hindi
I. Candidate
2. Father
3. Mother
4. Guardian
Note: Candidate, parents, guardians must sign the application wherever applicable, failings which
the form will be rejected.
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The application for admission should be accompanied by the following documents:
For B.P.T./DANP/DCBR
S.No. Documents Original/Photocopies Yes/No (office use
only)
1. Age Proof
2. Secondary
3. Senior Secondary (10+2)
4. Passport size Photographs (extra 4)
5. Stamp size photographs (4)
6. DD/IPO No. date Rs.
7. SC/ST/PH Category
8. OTHERS
9. Fitness Certificate (from a govt.
Doctor)
For M.P.T.
S.No. Documents Original/Photocopies Yes/No (office use
only)
1. Age Proof
2. Secondary
3. Senior Secondary (10+2)
4. Passport size Photographs (extra 4)
5. Stamp size photographs (4)
6. All mark sheets of B.P.T.
7. DD/IPO No. date Rs.
8. Fitness Certificate (from a govt. doctor)
9. Provisional/Degree Certificate
10. Internship Completion Certificate
11. Course Completions Certificate of
12.
B.P.T.
Transfer Certificate
13. Character Certificate
14. Migration Certificate
Note:
1. Attested copy of all mark sheets & documents must be attached with the form.
2. All original certificates and mark sheets must be brought at the time of Personal
interview/Admission and should not be sent with the application form.
3. Incomplete application forms without requisite certificates in the manner prescribed will be liable to
be rejected without any notice. No correspondence shall be entertained in this respect.
4. In case of any legal dispute, the jurisdiction will be limited to Udaipur Courts only and will not be
subject to any other courts (Except Supreme Courts), outside Udaipur.
Signature of Scrutinizer 1 …………………………………. 2 …………………………………
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For M. P. T. CANDIDATE
Fill according to your preference in the given table (in 1-5)
Branch
Preference
01. MPT in Musculo-skeletal disorder
02. MPT in Neurological & Psychosomatic disorder
03. MPT in Cardio Respiratory disorder & intensive care
04. MPT in Sports Physiotherapy
05. MPT in Pediatrics (Neuro)
_________________________________________________________
Decision of centralized admission board
Remarks: __________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
ADMISSION
(to be filled by office)
Admitted / Not Admitted ………………………………. Category ......................................
----------------------------- -----------------------------
PRINCIPAL
DEAN
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Specimen Signature ( for Office )
S No. Name Signature in
English
Signature in
Hindi
I. Candidate
2. Father
3. Mother
4. Guardian
______________________________________________________________
Specimen Signature ( for University )
S No. Name Signature in
English
Signature in
Hindi
I. Candidate
2. Father
3. Mother
4. Guardian
______________________________________________________________
Specimen Signature ( for Hostel )
S No. Name Signature in
English
Signature in
Hindi
I. Candidate
2. Father
3. Mother
4. Guardian
______________________________________________________________
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Form No……………
Roll No ……….
to be filled by office
APPLICATION FORM
FOR M.P.T. CANDIDATE
FOR APPEARING AT THE ENTRANCE TEST 2011 FOR ADMISSION TO
M.P.T. COURSES IN J.R. NAGAR RAJASTHAN VIDYAPEETH UNIVERSITY,
UDAIPUR.
To,
The controller of Examinations
J.R. Nagar Rajasthan Vidyapeeth University
Pratapnagar , UDAIPUR-313001 (Rajasthan)
All candidates
must affix their
latest passport
size photograph.
The candidate
should write
his/her name
on the photograph
Sir,
I have gone through the rules for admission to Institution of Faculty of Medicine as well as Syllabus
and nature of examination prescribed for the Entrance Test. I request permission to present myself
for the same, if eligible.
Place: .......................................
Date: .......................................
Yours faithfully
NAME IN BLOCK LETIERS : ...................................... ….
……………………………
(Signature of the Candidate )
Signature of the candidate in full to be taken in the examination hall & counter signed by the
invigilator.
Full signature in the Examination Hall
.............................
Candidate
.............................
Invigilator
Invigilators should verify the photograph on this form and the admission card and should ascertain
that the same candidate is giving the examination.
………………………………………………..
(Signature of the Centre Superintendent)
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JANARDAN RAI NAGAR RAJASTHAN VIDYAPEETH UNIVERSITY
DEPARTMENT OF PHYSIOTHERAPY
PRATAP NAGAR- UDAIPUR
ENTRANCE TEST 20….
(FOR M.P.T. CANDIDATE)
ADMISSION FORM
Form No. . …………………… Roll No. . ……………………
All candidates
must affix their
latest passport size
Photograph. The
candidate should
write his/her name
on the photograph
Please admit ...............................................................................................................................
(To be filled by the candidate)
Son/Daughter of .........................................................................................................................
(To be filled by the candidate)
INTRUCTION FOR THE GUIDANCE OF THE CANDIDATES
1. The examination will be held as per programming given above. The doors of
examination hall shall be opened at 9.30 A.M. on subsequent day and shall be closed
punctually at 1O.20A.M. No candidate shall be admitted to the examination hall after 20
minutes of the start of the examination.
2. A seat marked with Roll No. will be allotted to each candidate. The candidate should ensure
that he/she occupies the correct seat only.
3. Candidates are required to read carefully the instructions given in the question paper
booklet. They shall abide by the instructions issued during the examination, by the
invigilators or the centre superintendent.
4. No second question paper shall be issued to a candidate under anyircumstance.
5. Before attempting the answers, the candidate shall write his/her Roll Number, name of
the subject date, etc. at the place provided for the purpose on both the test booklets and
answer sheets. The candidates should write the answer in the cage (square) provided
for the purpose in the answer sheet of the booklet itself, otherwise his/her answer will not
be evaluated.
6. The candidate is forbidden to write his/her name or to make such signs at any place in
the booklets/answer sheets which may disclose his/her identity.
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7. No Guarantee is given to candidates regarding the order of the questions papers.
8. Candidates found acting in a manner which, in the opinion of the Invigilator, is liable to
give unfair advantage to him/her or to another candidate, shall be forthwith suspended
from the examination of the day by the Superintendent. The invigilator shall immediately
submit a report stating full facts of the case to the Superintendent who shall submit the
matter to the controller of examination for necessary action.
9. (i) No candidate shall bring any objectionable material (i.e paper, books, notes, etc.) in to
Examination hall for the purpose of being used for answering the question paper. The
Invigilator and the Examination Supervisory Staff shall be competent to take search of any
candidate to find out whether the candidate possesses any objectionable material.
(ii) Any candidate shall possessing objectionable material, or resisting search by the invigilator/examination
supervisory staff shall be punishable as per the rules concerning unfairmeans.
10. No candidate shall leave his/her seat when the examination is going on without the
special permission of the Invigilator-incharge. He/she shall not leave the examination
room finally until he/she has handed over his/her answer-book even though it may be
blank. If a candidate wishes to invite the attention of an invigilator, he/she shall stand up
in his/her place.
11. In case the original Admission card is lost, its duplicate copy may be obtained on application
together with photograph from the Centre Suptd. on payment of a fee of Rs.50/-.
12. If you have any complaint in regard to any question, the same should be submitted
through the Centre Suptd. within 24 hours of the examination of that question paper for
the consideration of the University Authorities otherwise cognisance of the same will not
be taken.
CONTROLLER OF EXAMINATION
Address: (TO BE FILLED BY THE CANDIDATE)
To,
______________________________
______________________________
______________________________
______________________________
Pin: _____________________
Affix Postage Rs.3/
Note: Candidates should write legibly in the space provided above, his/her full postal address
for dispatch of the Admission Card.
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