MDS STUDENT INFORMATION FORM

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1 TPCT S TERNA DENTAL COLLEGE Sector-22, Phase-II, Nerul, Navi Mumbai MDS STUDENT INFORMATION FORM Academic Year Date: Admission of Subject : Name: Address: (Surname) (First Name) (Middle Name) Tel: Res: Off: Cell: 1) 2) Date of Birth: Age as on today Fathers Occupation: Category: Open /SC/ST/VJNT/SBC/OBC SUB-CASTE BDS Registration No. SSC (10 th Std) Student S Academic Information Marks Obtained in Examination Examination University / Board Total Marks Out of HSC (12 th Std) PCB HSC % Aggregate I BDS II BDS III BDS IV BDS (Sem-I) IV BDS (Sem-II) Marks Obtained at PGD CET-2016 Examination Particulars PGD CET Seat Number SML Number Marks Obtained Note: Form will not be given unless & until Original Certificates are produced. Signature of student with name Signature of Parent with name

2 Lists of documents to be submitted along with MDS admission form. 1. Nationality/Domicile Certificate or Valid Indian Pass Port 2. PGD CET-2016 Mark Sheet 3. Selection letter (net copy from DMER website) 4. Degree Certificate (BDS) 5. Passing Certificate (BDS) 6. Internship Completion Certificate up to 31/03/ Registration certificate from Central/State Council (only valid) 8. Registration Renewal copy (latest) 9. Caste Certificate (If applicable) 10. Caste Validity (If applicable) 11. Non Creamy Layer Certificate (If applicable) up to 31/03/ College Leaving / Transfer Certificate 13. Attempt Certificate duly signed by Head of the institute. 14. Copy of Gazzete for change in name (if Applicable) 15. Migration Certificate by University (non-muhs students only) 16. Affidavit of Gap (if applicable) 17. Medical Fitness Certificate (Annexure - F) 18. Physical Handicapped Certificate (if Applicable) 19. Copy of Preference Form 20. Documentation for in-service personal (if applicable) a) Deputation Certificate b) No objection certificate c) University approval certificate for teacher in the concern subject d) Experience certificate. 21. SSC Passing Certificate 22. HSC Passing Certificate 23. First to Final year BDS Mark sheet (Xerox copies) 24. Birth Certificate 25. Undertaking for fees on Rs.100/- stamp paper with Notarized 26. Undertaking for Ragging on plain paper (Annexure-I & II) (Student & parent) 27. Pass Port size Photograph (02 No.) Note: Submit attested Xerox Copies of all documents (sr.no. 1 to 24) in three sets.

3 ACADEMIC FEES (Interim Fee) I YEAR MDS COURSE (ACADEMIC YEAR ) TUITION FEES 2,88,270 D.D. No. 1 CAUTION MONEY DEPOSIT 10,000 (Refundable) Total Fees 2,98,270 MUHS ELIGIBILITY FEE MUHS ELIGIBILITY FEE (For all students) HOSTEL FEE 44,000 D.D. No. 2 HOSTEL FEES 40,000 D.D. No. 3 CAUTION MONEY DEPOSIT 10,000 (Refundable) Total Fees 50,000 Rs. 2,98,270 /- In the Name of DEAN, TERNA DENTAL COLLEGE, NERUL, NAVI MUMBAI. Rs. 44,000/- In the Name of National Insurance Company (AMARTYA SIKSHA YOJANA POLICY) AMARTYA SIKSHA YOJANA POLICY (As per GR No. MED/100/880/CR-129/Edu-1, Dated 13/10/2003) * Please make separate 04 D.D s as mentioned above names. DEAN, TERNA DENTAL COLLEGE, NERUL, NAVI MUMBAI. Rs. 50,000/- In the Name of TERNA PUBLIC CHARITABLE TRUST, NERUL, NAVI MUMBAI. 650 D.D. No. 4 Rs. 650/- In the Name of NATIONAL INSURANCE COMPANY LIMITED PAYABLE AT KOLHAPUR

4 ON STAMP PAPER ON RS.100/- WITH NOTARIZED UNDERTAKING I,Dr. Son/Daughter/wife of Shri. Indian inhabitant, residing at do solemnly affirm and state as under: 1. I say that I have appeared for the PGD CET-2016 examination conducted by DMER to secure admission in the academic year in Dental Colleges. 2. I say that solely on the basis of merit I have been admitted to the Terna Dental College in MDS course in 85% Quota in the academic year I say that at the time of securing my admission I have paid a sum of Rs. 2,88,270/- as fees for MDS course. 4. I say that I am fully aware that the aforesaid fees by me are interim fees and are subject to revision at any time. In the event of the fees being increased by the appropriate authority/court, I hereby undertake to pay the difference amount of the fees within a period of 7 days from being notified. I hereby also undertake that I will not challenge the increase in the amount of the fees for any reason whatsoever. Solemnly affirmed at Mumbai This day of Before Me Identified by me : NOTARY

5 On plain paper ANNEXURE I UNDERTAKING BY STUDENT 1) I, s/od/omr./mrs./ms been admitted to Terna Dental College, Nerul have received a copy of the UGC Regulations on Curbing the Menace of Ragging in Higher Educational Institutions, (hereinafter called the Regulations ) carefully read and fully understood 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 of 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 behaviour or act that may be constituted as ragging under clause 3 of the Regulations. b) I will not participate in or abet or propagate through any act of commission or omission that may be constituted as ragging 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:

6 On plain paper ANNEXURE II UNDERTAKING BY PARENT/GUARDIAN 1) I Mr./Mrs./Ms. (full name of parent / guardian) father / mother / guardian of, having been admitted to Terna Dental College, Nerul, 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 understood 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 of the penal and administrative action that is liable to be taken against my ward in case he/she is 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) My ward will not indulge in any behaviour or act that may be constituted as ragging under clause 3 of the Regulations b) My ward will not participate in or abet or propagate through any act of commission or omission that may be constituted as ragging under clause 3 of the Regulations 5) I hereby affirm that, if found guilty of ragging, my ward is liable for punishment according to clause 9.1 of the Regulations, without prejudice to any other criminal action that may be taken against my ward under any penal law or any law for the time being in force. 6) I hereby declare that my ward has 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, the admission of my ward is liable to be cancelled. Declared this day of month of year. Signature of deponent Name: Address: Tele./Mobile No:

STUDENT INFORMATION FORM

T.P.C.T. S TERNA DENTAL COLLEGE Sector-22, Nerul, Navi Mumbai 400706 STUDENT INFORMATION FORM Academic Year-2017-18 Date: Name: Mr./Ms. (Surna me) (First Name) (Middle Name) Correspondence Address: Permanent