APPLICATION FORM FOR ADMISSIONS INTO I YEAR BDS COURSE UNDER C CATEGORY (NRI QUOTA) FOR THE ACADEMIC YEAR

ST. JOSEPH DENTAL COLLEGE Duggirala, Eluru-534003, West Godavari District, Andhra Pradesh Recognized by Govt. of India & Dental Council of India, New Delhi vide Lr. No. V-12017/2001-PMS (DE) dt 21.05.07 and Affiliated to Dr.NTR University of Health Sciences, Andhra Pradesh, Vijayawada Ph: 08812-277583, 277633 APPLICATION FORM FOR ADMISSIONS INTO I YEAR BDS COURSE UNDER C-CATEGORY (NRI QUOTA) FOR THE ACADEMIC YEAR 2016-17 Application No. : Registration No. : Total No. of enclosures ( ) Read the Regulations carefully before filling the application form: NOTE: a) The requirement of passing NEET and guidelines for selection and admission are strictly as per orders of State Govt./Dr. NTR UHS; b) Filled-in application forms shall be submitted in person to the Admissions Cell, Office of the Principal, St. Joseph Dental College, Duggirala, Eluru-534003, Andhra Pradesh on or before 1600 hrs on 23.07.2016; c) Applications unaccompanied by required attested certificates/documents or applications with incomplete entries and ineligible applications shall stand rejected automatically. Please do not leave any column blank. Where information is NIL write NO/NIL; d) Applications of the candidates who furnish incorrect information, enclose false/incorrect certificate or approach through agents shall stand rejected automatically; e) Application form shall be filled-in in English by the candidate in his/her own handwriting; f) No enclosures will be accepted after submission of application form; Passport size colour photo attested by Gazetted Officer/Principal of concerned college where applicant studied last. g) The envelope/cover must be superscribed For Admission into I Year BDS Course-2016-17. 1. Full Name : (in block letters as per Intermediate (or) its equivalent certificate) 2. Sex : Male Female 3. Name of the Father/Mother : 4. Name of the Guardian (if parents are not alive) : 5. Occupation of the Parent/Guardian : 6. Date of Birth as entered in SSC or its equivalent Examination (Proof to be submitted): 7. Age as on 31 st December 2016 : 8. Address (complete Postal Address): i) D/o. S/o. C/o. : ii) Door No./House No. : Page-2

iii) Rood/Street iv) Village/Town/City : : v) District/State : vi) PIN code vii) Phone No. (with STD code) viii) Cell No. : : : 9. Place of Birth (also mentioned District/State) : 10. Mother Tongue : 11. Nationality & Religion : 12. Native District and State : 13. Educational Qualifications (Particulars of Qualifying examination): i) Name of Qualifying Examination (Intermediate or its equivalent examination) (indicate month & year of appearance) Qualifying Examination Month & Year of appearance ii) H.T. No., Subjects, Class (or) Division in qualifying Examination (intermediate or its equivalent examination): a) Hall Ticket No. : b) Optional Subjects : c) Class (or) Division : 14. EAMCET/ MCET-AC NEET (if appeared) : H.T. No. Rank Total Marks 15. Total Marks obtained in Science subjects in the qualifying examination (Intermediate or its equivalent examination Theory+Practicals): Marks Marks Obtained Theory Botany Zoology Physics Chemistry Total Practi cals Theory Practi cals Theory Practi cals Theory Practi cals Theory Practi cals Grand Total Maximum Marks % upto Two decimal place 16. Any other particulars the candidate desires to furnish : Signature of the Candidate Page-3

CERTIFICATES/DOCUMENTS TO BE SUBMITTED ALONG WITH THE APPLICATION FORM: Attested copy of:- 1. SSC or any equivalent examination showing date of birth and other particulars of the candidate, 2. Memorandum of Marks of the qualifying examination (Intermediate or its equivalent examination) making the candidate eligible for admission, 3. Study & Conduct Certificate of Intermediate or its equivalent study, 4. Transfer Certificate of Intermediate or its equivalent Education, 5. Migration Certificate (If applicable), 6. Equivalence Certificate (If applicable), 7. EAMCET/MCET-AC -2016/NEET Hall Ticket and Rank Card (If appeared), 8. Proof of Identity and Residence of NRI Sponsorer. Note: 1. 8 Nos. of Passport size colour photographs are also to be submitted. Note: 2. Xerox copies of the certificates must be attested by a Gazetted officer. Original copy of:- 9. Declaration duly signed by the candidate and his/her Parent/Guardian (format as given at Page-5), 10. Service Bond for rendering compulsory Rural Dental Service (format as given at Page-6), 11. Study Bond to Principal, St. Joseph Dental College (format as given at Page-7), 12. Study Bond to Dr. NTR UHS (format as given at Page-8), 13. Disciplinary declaration by both the candidate and his/her Parent/Guardian(format as given at Page-9), 14. Irrevocable Bank Guarantee (format as given at Page-10), 15. Affidavit signed by the NRI candidate starting that he/she is a Ward of NRI duly notarized (format as given at Page-11), 16. Undertaking duly signed by the NRI financial supporter of the candidate duly notarized (format as given at Page 12), 17. Xerox copy of address proof of NRI Sponsorer in the country where he/she is residing, 18. Code of conduct and Anti-Ragging Affidavit by the Student (format as given at Page-13), 19. Code of conduct and Anti-Ragging Affidavit by the Parent/Guardian (format as given at Page-14), 20. Acknowledge Card (format as given at Page-15). Page-4

DECLRATION BY THE CANDIDATE I hereby solemnly and sincerely affirm that the statement made and information furnished by me in the application form and also in all the enclosures thereto submitted by me are true and correct. I have not kept any information secret. Should it however be found that any information furnished therein is fraudulent, incorrect or untrue in material particulars at any time during the pursuit of the course, I realize that my selection or admission to the course is liable to be cancelled and I am liable for criminal prosecution. Further, I also agree to forgo my seat and fees paid there of in St. Joseph Dental College, Eluru, unconditionally and I will not move any court of law in this connection. I am also fully aware that I may not be permitted to appear for any University Examinations unless I show required percentage of attendance to Theory and Practical classes and performance in Internal Assessment Examinations in concerned subjects in fulfillment of regulations laid down by Medical Council of India and Dr. NTR University of Health Sciences. I shall abide by the decision of the Selection Committee/Principal, St. Joseph Dental College, Eluru, which shall be final and binding on me. SIGNATURE OF THE CANDIDATE DECLRATION BY THE PARENT/GUARDIAN I have fully read the information furnished by my son/daughter/ward in his/her application form for admission to I BDS Course in St. Joseph Dental College, Eluru and I affirm that the information furnished is true to the best of my knowledge. Should it however be found that any information furnished therein is fraudulent, incorrect or untrue in material particulars at any time during the pursuit of the course and if it is proved that the information was fraudulent, I am liable for criminal prosecution and also forfeit the seat allotted to my ward and fees paid thereof and abide by other conditions as specified above. OFFICIAL ADDRESSS : OFFICIAL ADDRESSS : SIGNATURE OF THE PARENT/GUARDIAN Note: 1. No Application form is deemed complete unless this declaration is signed by both the candidate and the Parent/guardian (if parents are not alive) 2. The above Bond Format is to be typed on a Non-Judicial Stamp paper of the value of Rs. 100/- Page-5

SERVICE BOND I, Mr./Ms. selected for BDS Course for the year 2016-2017 and admitted in St. Joseph Dental College, Duggirala, Eluru-534003 under C Category (NRI Quota) do hereby undertake that as per G.O. Ms. No. 166, HM & FW (E1) Dept., dated 20.07.2010, I shall provide Compulsory Rural Dental Service for a period of ONE YEAR, immediately following the successful completion of the BDS course including the completion of House Surgency. WITNESS: Signature of the Candidate SURETIES: 1. Signature: 1. Signature Name and Address in full Name and Address full 2. Signature: 2. Signature Name and Address in full Name and Address full Note: 1.The above Bond format should be typed on a Non-Judicial stamp paper of the value of Rs. 100/-. 2. Sureties should be of two permanent Gazetted Officers of A.P. State Government. Page-6

STUDY BOND I, Mr./Ms. selected for BDS course for the year 2016-17 and admitted in St. Joseph Dental College, Duggirala, Eluru-534003 under C- Category (NRI Quota) do hereby undertake to complete the said course as per the requirements of the University. In the event of my discontinuation the studies after joining the course or not completing the studies within the stipulated period of the above said course, I undertake to pay to the Principal, St. Joseph Dental College, Duggirala, Eluru-534003 a sum of Rs. 4,50,000/- * per annum for the remaining period of the course from the date of discontinuation. * Subject to change WITNESS: Signature of the Candidate SURETIES: 1. Signature: 1. Signature Name and Address in full Name and Address full 2. Signature: 2. Signature Name and Address in full Name and Address full Note: 1.The above Bond format should be typed on a Non-Judicial stamp paper of the value of Rs. 100/-, 2. One of the Sureties should be Father/Mother/Guardian of the candidate, 3. The second Surety should be a permanent Gazetted Officers of A.P. State Govt. Service. 4. Proof of address of the said two Sureties should be enclosed (Aadhar Card/Voter Card/Ration Card) Page-7

STUDY BOND I, Mr./Ms. selected for BDS course for the year 2016-17 and admitted in St. Joseph Dental College, Duggirala, Eluru-534003 under C-Category (NRI Quota) do hereby undertake to complete the said course as per the requirements of the University. In the event of my leaving the studies after joining the course, I undertake to pay to Dr. NTR University of Health Sciences a sum of Rs. 50,000/- * (Rupees Fifty Thousand Only) and refund the amount received as stipend upto that date to Government. * subject to change WITNESS: Signature of the Candidate SURETIES: 1. Signature: 1. Signature Name and Address in full Name and Address full 2. Signature: 2. Signature Name and Address in full Name and Address full Note: 1.The above Bond format should be typed on a Non-Judicial stamp paper of the value of Rs. 100/-, 2. One of the Sureties should be Father/Mother/Guardian of the candidate, 3. The second Surety should be a permanent Gazetted Officers of A.P. State Govt. Service. 4. Proof of address of the said two Sureties should be enclosed (Aadhar Card/Voter Card/Ration Card) Page-8

DISCIPLINARY DECLARATION I, Mr./Ms. S/o. / D/o. resident of provisionally selected for Admission into I Year BDS during the Academic Year 2016-2017 at St. Joseph Dental College, Eluru, do hereby solemnly affirm and state that I undertake to abide by all Rules and Regulations of St. Joseph Dental College that are already in vogue and that may come into force from time to time. I further undertake to make good any loss sustained by St. Joseph Dental College, Eluru due to my negligence. I am aware that any involvement in any manner in the acts that break or contravene the Rules and Regulations of St. Joseph Dental College attract punishment/disciplinary action. I further agree that any disputes between the Management/administration and students are subject to the Jurisdiction of Courts at Eluru only and the jurisdiction of all other courts are hereby excluded. Signature of the Candidate I, Parent/Guardian of Mr. /Ms. undertake to see that my Ward Mr. /Ms. abides by all the Rules and Regulations of St. Joseph Dental College as per the above declaration. Signature of the Parent/Guardian (Relationship with the candidate is to be mentioned) Page-9

B.G.No.: Date of Issue : B.G. Amount: Rs. 13,50,000/- * subject to change Date of Expiry : IRREVOCABLE BANK GUARANTEE We,. Bank, having its Branch at. (hereinafter to be referred as BANK ) do hereby issue this irrevocable Bank Guarantee at the request, upon application and on behalf of Mr. / Ms..., S/o. / D/o. (hereinafter to be referred as STUDENT ) in favour of St. Joseph Dental College, Duggirala, Eluru- 534003, West Godavari District, Andhra Pradesh, represented by its Secretary & Correspondent (hereinafter to be referred as BENEFICIARY ). WHEREAS the above named student got admitted into BDS course for the Academic Year 2016-17 for the duration of full course in the Beneficiary Institute and paid the 1 st year fee of Rs.4,50,000/- and is also obligated to pay the balance fee of Rs.13,50,000/- for the remaining 2 nd, 3 rd and 4 th year period of course. WHEREAS as per the conditions for admission and Rules governed thereunder, the Student is required to furnish an Irrevocable Bank Guarantee to the Beneficiary from any Nationalized Bank to protect the interest of the Beneficiary in the event of any default of the Student in payment of balance fee during the entire course. Hence, in the event of default on the part of the student in payment of balance fee of Rs.13,50,000/- or any part thereof during the balance course period, the Bank on behalf of the student thereby irrevocably, unequivocally and unconditionally agrees and undertakes to pay forthwith the said sum of Rs.13,50,000/- or part thereof to the Beneficiary without any condition, protest demur or proof and without reference to any consent of the student and irrespective of and not withstanding any contest / objection from the student or the existence of any dispute between the student and the beneficiary upon the beneficiary invoking this Bank Guarantee with the letter of Invocation by surrendering this Original Bank Guarantee to the Bank. The Bank agrees to make the payment of invoked amount to the Beneficiary simultaneously on the Beneficiary submitting the Letter of Invocation along with Original Bank Guarantee. The Bank further agrees that this Guarantee shall constitute an independent and autonomous contract between the Bank and the Beneficiary and shall not in any way be affected by any dispute or difference between you viz., the Beneficiary and the student of whatsoever nature. Finally, the Bank confirms that a mere letter from the Beneficiary that there has been a default on the part of the Student in payment of the fees, shall without any other or further proof be final, conclusive and binding on the Bank to treat the same as a valid invocation and for making the simultaneous payment of the demanded amount upto the maximum of Rs.13,50,000/-. This Bank Guarantee shall remain in force upto and all claims should be received by the Bank on or before the said date. THE BRANCH MANAGER, BANK, BRANCH. Note: The above Irrevocable Bank Guarantee should be typed on white sheet of paper. Page-10

AFFIDAVIT (To be given by the applicant who seeks admission under C-Category (NRI Quota) I, Mr./Ms. S/o, D/o, resident of having applied for admission into BDS Course under C-Category (NRI Quota) seats for the Academic Year 2016-17 in St. Joseph Dental College, Eluru, do hereby declare and state as under:- That I, Son/Daughter/Ward of Mr./Mrs., resident of (place and country name) That I have studied Intermediate/10+2/Equivalent course in India at affiliated to Board of Intermediate Education, A.P., Hyderabad, India. That my Parents/Guardian, as such, are paying my fee for my BDS course. I declare that the facts stated above are true and correct and I am liable for any action in the event of the authorities coming to know of any concealment of facts. Name and Signature of the Candidate Note: 1. The above Affidavit format should be typed on a Non-Judicial Stamp paper of the value of Rs. 100/- 2. The Affidavit should be NOTARISED 3. Proof of NRI Candidate s NRI Parent s/guardian s full address is to be enclosed. Page-11

UNDERTAKING (TO WHOMSOEVER IT MAY CONCERN) I, Sri/Smt. S/o,/W/o residing at hereby declare and confirm that Mr./Ms. is my son/daughter/ward and seeking admission into BDS course under C-Category (NRI Quota) for the Academic Year 2016-17 in St. Joseph Dental College, Eluru, Andhra Pradesh, India. I hereby irrevocably agree and undertake to provide financial support to him/her by payment of entire fees and other expenses for pursuing BDS Course in St. Joseph Dental College, Eluru, Andhra Pradesh, India. Name and signature of the NRI Note: 1. The above Undertaking format should be typed on a Non-Judicial stamp paper of the value of Rs. 100/- 2. The above Undertaking should be NOTARISED. 3. Proof of NRI s full address in the country where he/she is residing is to be enclosed. Page-12

AFFIDAVIT BY THE STUDENT I, (full name of student with University Roll Number) S/o./D/o. Mr./Mrs./Ms., having been admitted to 1 st YEAR BDS COURSE at St. Joseph Dental College, Eluru, for the Academic Year 2016-17have 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 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 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: Note: The above AFFIDAVIT BY THE STUDENT format is to be typed on a white sheet of paper only (Not to be typed on a Non-Judicial stamp paper) Page-13

AFFIDAVIT BY PARENT/GUARDIAN I, Mr./Mrs./Ms. (full name of parent/guardian) father/mother/guardian of (full name of student with University Roll Number), having been admitted for the Academic Year 2016-17to 1 st YEAR BDS COURSE at St. Joseph Dental College, Eluru, 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 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) My Ward will not indulge in any behavior 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 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, I am aware that my admission is liable to be cancelled. Declared this day of month of Year. Signature of deponent Name: Address: Telephone/Mobile No: Note: The above AFFIDAVIT BY PARENT/GUARDIAN format is to be typed on a white sheet of paper only (Not to be typed on a Non-Judicial stamp paper) Page-14