First MBBS Admission 2016-17

Requirements at time of reporting to the college

1 Pass Port size photo – 04

2 All Original Certificates Below

1. Allotment Letter (CET/AIQ)

2. SSLC Marks Card (10th)

3. PUC Marks Card (10 + 2)

4. T.C. + Study Certificate

Caste Certificate, Income Certificate

( Cat I/IIa/IIb/IIIa/IIIb/SC/ST)

5. Physical Fitness Certificate With Blood Groups

(Any Govt. Hospital)

6. Eligible Certificate/ Migration Certificate (All India Quota/CBSE) From

RGUHS, Bangaluru.

7. CET & PMT (AIQ) Marks (Net Copy)

8. Total 3 Sets Xerox Copies Of All Certificates.

(Candidates Should Maintain Adequate Number Of Xerox Sets Of All

Documents For Themselves Separately.)

3 E – Stamp Bonds – Total 04, details of which uploaded on website.

College fees structure 1. CET General Candidate – Rs 8,375

2. CET SC/ST/CAT-I Candidates –Rs 15,875

3. AIQ- Rs 25,075

Kindly go through the Admission form which has been uploaded on website-

www.kimskodagu.kar.nic.in

-sd-

Director and Dean

Kodagu Institute of Medical Sciences

Madikeri

No: KoIMS/UGC(1) 001 /2016-17 Dated: 04-07-2016

Under Graduates 1st year MBBS Fees structure 2016-17

Sl. No Particulars 1st Year

Admission

AIQ

1st Year

Admission

SC/ST

Other Category

CET 1st Year

Admission

College Fees

(CET)

1. Tuition Fee 9200 9200

2. Helinet 4600 4600 4600

3. Registration 3000 3000 2500 1000

4. Admission 500 500 500

5. SWF (41/2 Yrs) 450 450 150 300

6. Sports (41/2 Yrs) 1125 1125 150 975

7. Admission 400 400 400

8. CET Fees 500 500

9. ID 100 100 100

10. Student Association 500 500 500

11. Sports 500 500 250 250

12. Library 1500 1500 1500

13. Magazine 300 300 150 150

14. Lab 500 500 500

15. Med. Exam 150 150 150

16. Caution 1000 1000 1000

17. Alumini 750 750 750

Total 25075 15875 16700 8375

To be paid into Ac No- 64199775815

Name: KoIMS Student FEE ACCOUNT

Branch: SBM, Madikeri Branch

-sd-

Director and Dean

Kodagu Institute of Medical Sciences

Madikeri

Admission Form

(Details to be entered in block letters only)

SEAT ALOTTMENT No.:

1 Name (As mentioned in SSLC / 10th

Standard)

2 Gender

3 Date of Birth

3 Father Name

4 Mother Name

5 Permanent Address

Communication Address:

(Phone number and email)

6 Nationality 7 Religion

8 Caste & category

9 Mother tongue 10 Seat type 11 All India Rank 12 CET Rank

13 Qualifying Exam (II PUC / 12th

)

14 Registration No of Qualifying Exam

(II PUC / 12th

)

Recent passport size photo with self attestation

15 Year of passing 16 University/Board

17 Optional Subjects( PUC marks) Max Marks Marks Secured

Physics Chemistry Biology Mathematics English

Kannada / Hindi

PCB Total 18 Entrance Hall Ticket No 20 Entrance Marks (along with Max.

Marks)

21 Entrance Percentage 22 CET Entrance Rank 23 Date of Admission

24 Blood group 25 State & Native District 26 Urban/Rural 27 Annual Income 28 In case of emergency, contact

details

28 Remarks

DECLARATION

All the entries made above are true to best of my knowledge and I am directly responsible

for any fallacies

Signature of the Student Signature of the Parent or Guardian

Verifying Officer & Designation:

Place:

Date:

I MBBS ADMISSION CHECKLIST

(Three Sets of Attested Photocopies need to be submitted)

Sl.

No

Type of Documents Submitted

(Yes/No)

Remarks

1. Recent Passport photos (4 Nos.)

2. Copy of Fees Paid At Allotment

Centre

3. Copy of Fees Paid At KoIMS,

Madikeri

4. CET/AIPMT admission ticket

5. KET/ AIPMT Admission Order

6. Seat allotment number

7. Entrance examination Marks

Statement

8. SSLC/10th Standard Marks Statement

9. PUC/12th Standard Marks Statement

10. Eligibility Certificate( 10+2 students)

11. Caste Certificate(SC & ST students

should produce caste Certificate in

English Only)

12. Transfer Certificate(10+2)

13. Study Certificate ( for 12th year)

14. Kannada Medium/Rural Study

Certificate

15. 371 J Eligibility Certificate if

applicable.

16. Affidavit for MBBS admission

17. Affidavit for Anti-ragging( by student)

18. Affidavit for Anti-ragging( by Parent)

19. Affidavit for Rural service after

completion of MBBS

20. Physical Fitness Certificate

DECLARATION

Photo Copies of all documents submitted for MBBS admissions are true and correct to the

best of my knowledge. I also accept that my admission to I MBBS Course at this institution

is provisional and subject to approval from RGUHS, Bangalore, Karnataka and MCI, New

Delhi.

Place: Signature of Student

Date:

FILE FOLDER NO.

SEAT

ALLOTMENT

NUMBER

SEAT TYPE

STUDENT’S NAME

FATHER’S NAME

DOB

AGE

DATE OF

ADMISSION

CONTACT

NUMBER

AFFIDAVIT- I

Bond value: Rs. 50/- e-stamp/bond;

1st Party: Parents’ name 2nd Party: Govt. of Karnataka

UNDERTAKING MBBS DEGREE PROGRAMME AS PER RGUHS CURRICULUM

I_____________________________________________________ Son / Daughter of

______________________________________ (herein after called the Natural Guardian of the

Student) hereby given an undertaking that on admission to I MBBS at KODAGU INSTITUTE

OF MEDICAL SCIENCES, MADIKERI, KODAGU DISTRICT, during the year 2016-17, read

the rule No.11of the ordinance of Governing M.B.B.S. Degree Programme of Rajiv Gandhi

University of Health Sciences, Bangalore, vide Notification No. ACA/BOS-27/97-98, dated:

24.03.1998, and I shall abide / by the ordinance. That no student shall be permitted to join Phase-

II (Para Clinical & Clinical) Group of subjects until he / she passes in the Phase-I (pre-clinical)

subject for which he / she will be permitted not more than four chances (Actual Examination)

provided four chances are completed within three years from the date of enrolment.

Signature of the Parents with full address

Witness: 1)

2)

SEAL & SIGNATURE OF NOTARY

AFFIDAVIT –II- BY THE STUDENT

Anti ragging concern- Proforma

Bond value: Rs. 20/- e-stamp/bond;

1st Party: Student’s name 2nd Party: KoIMS, Madikeri.

1. I, _____________________________ (full name of the student

with admission/registration/enrolment number) s/o d/o Mr./Mrs./Ms.

____________________ having been admitted to __________________________ (name of

the institution), have received a copy of the UGC Regulations on Curbing the Menace of

Ragging in Higher Educational Institutions, 2009, (hereinafter called the “Regulations”)

carefully read and fully understand the provisions contained in the said Regulations.

2. I have, in particular, perused clause 3 of the Regulations and am

aware as to what constitutes ragging.

3. I have also, in particular, perused clause 7 and clause 9.1 of the

Regulations and am fully aware or the penal and administrative action that is liable to be

taken against me in case I am found guilty of or abetting ragging, actively or passively, or

being part of a conspiracy to promote ragging.

4. I hereby solemnly aver and undertake that a) I will not indulge in

any behavior or act that may be constituted as ragging under clause 3 of the Regulations. b) I

will no participate in or abet or propagate through any act of commission or omission that

may be constituted as tagging under clause 3 of the Regulations.

5. I hereby affirm that, if found guilty of ragging, I am liable for

punishment according to clause 9.1 of the Regulations, without prejudice to any other

criminal action that may be taken against me under any penal law or any law for the time

being in force.

6. I hereby declare that I have not been expelled or debarred from

admission in any institution in the country on account of being found guilty of, abetting or

being part of a conspiracy to promote, ragging and further affirm that, in case the declaration

is found to be untrue, I am aware that my admission is liable to be cancelled.

Declared this ___________________ day of ____________ month of _______________

year. _______________________

Signature of deponent

Name:

Address:

Mobile No. :

VERIFICATION

Verified that the contents of this affidavit are true to the best of my knowledge and no part of

the affidavit is false and nothing has been concealed or misstated therein. Verified at

_______________ (place) this ___________ (day) of ______________________ (month),

________________________ (year). _______________________

Signature of deponent

Solemnly affirmed and signed in my presence on this the

______________________________ (day) of ___________________ (month),

_______________________ (year) after reading the contents of this affidavit.

OATH COMMISSIONER

AFFIDAVIT –III- BY THE PARENT/ GUARDIAN

Anti ragging concern- Proforma

Bond value: Rs. 20/- e-stamp/bond;

1st Party: Parent’s/ Guardian’s Name 2nd Party: KoIMS, Madikeri.

1. I,

Mr./Mrs./Ms.__________________________________________ (full name of

parent /guardian /father /mother /guardian of, _____________________ (full name of

student with admission/registration/enrolment number), having been admitted to

__________________________ (name of the institution), have received a copy of the

UGC Regulations on Curbing the Menace of Ragging in Higher Educational

Institutions, 2009, (hereinafter called the “Regulations”) carefully read and fully

understand the provisions contained in the said Regulations.

2. I have, in particular, perused clause 3 of the Regulations and am

aware as to what constitutes ragging.

3. I have also, in particular, perused clause 7 and clause 9.1 of the

Regulations and am fully aware or the penal and administrative action that is liable to

be taken against me in case I am found guilty of or abetting ragging, actively or

passively, or being part of a conspiracy to promote ragging.

4. I hereby solemnly aver and undertake that a) I will not indulge in

any behavior or act that may be constituted as ragging under clause 3 of the

Regulations. b) I will no participate in or abet or propagate through any act of

commission or omission that may be constituted as tagging under clause 3 of the

Regulations.

5. I hereby affirm that, if found guilty of ragging, I am liable for

punishment according to clause 9.1 of the Regulations, without prejudice to any other

criminal action that may be taken against me under any penal law or any law for the

time being in force.

6. I hereby declare that I have not been expelled or debarred from

admission in any institution in the country on account of being found guilty of,

abetting or being part of a conspiracy to promote, ragging and further affirm that, in

case the declaration is found to be untrue, I am aware that my admission is liable to

be cancelled.

Declared this ___________________ day of ____________ month of

_______________ year.

Signature of deponent

Name:

Address:

Mobile No. :

VERIFICATION

Verified that the contents of this affidavit are true to the best of my knowledge and no

part of the affidavit is false and nothing has been concealed or missstated therein.

Verified at _______________ (place) this ___________ (day) of

______________________ (month), ________________________ (year).

Signature of deponent

Solemnly affirmed and signed in my presence on this the __________ (day) of

________________ (month), _______________________ (year) after reading the

contents of this affidavit.

OATH COMMISSIONER

AFFIDAVIT –IV

Rural service for MBBS students

Bond value: Rs. 100/- e-stamp/bond

1st Party: Student’s Name 2nd Party: Government of Karnataka

I,MR . / Kum

………………………………………………………………………………………………… S/o.

/ D/o………………….…………………………………………… a candidate with ‘CET–2016’

Admission Ticket No…………………… residing at

……….…………………………………………………………………………….

………………………………………………………………………………………………………

…………………………………

………………………………………………………………………………………………………

………………………………… have on my own volition allotted a MBBS seat on

…………..…………………............................... In

……………………………………………………………….vide admission order number

…………………………............... dated ………………….... and do hereby undertake as

follows:

In accordance with the Amendment to Rule 11 of the Karnataka Selection of Candidates for

Admission to Governmen t seats in Professional Educational Institutions Rules, 2006, vide

Government Notification – 1. No.HFW 79 RGU 2011 dated 17-07-2012, I am prepared on

completion of the course to serve in any Primary Health Center or Primary Health Unit situated

in Rural Areas in the State of Karnataka for a minimum period of ONE year, failing which I

render myself liable to pay a penalty of Rupees Ten Lakhs to Government of Karnataka.

What is stated above is true and correct and I and my parent hereby undertake to act accordingly.

Signature of the candidate Signature of the Parent

(Father / Mother)

Date:……………………..

Place:......................