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 Address: Contact No Student : Parents: Email ID (student) : Date of Birth: Age as on today Male/Female Aadhar Card No.: CAP/Vacancy Fathers/Guardian Occupation: Fathers/Guardian Annual Income 2016-17 Caste: Open / SC / ST / VJNT / SBC / OBC SUB-CASTE Marks Obtained at HSC Examination Student S Academic Information Physics Chemistry Biology Total PCB % Aggregate % Marks Obtained at NEET UG Examination - 2017 Roll No Particulars NEET UG - 2017 NEET All India Rank Marks Obtained/Out of NEET Percentile Score The information provided above is correct as per my knowledge, howeve r if found incorrect, I will be responsible for the sa me. Signature of student Signature of Parent/Guardian
LIST OF ORIGINAL DOCUMENTS & XEROX COPIES (03 SETS) TO BE SUBMITTED ALONG WITH ADMISSION FORM. 1. Nationality/Domicile Certificate or Valid Indian Pass Port 2. SSC Passing Certificate 3. HSC Mark Sheet 4. NEET UG - 2017 Mark Sheet 5. Selection List (Net copy from NEET-2017 website) 6. Caste Certificate (If applicable) 7. Caste Validity (If applicable) 8. Non Creamy Layer Certificate (Valid up to March-2018) 9. College Leaving Certificate / Transfer Certificate (LC/TC) 10. Migration Certificate (if applicable) 11. Gap Certificate Affidavit on Rs.100 stamp paper (if applicable) 12. Medical Fitness Certificate as per Annexure-H 13. Medical Haemogram Report 14. Physical Handicapped Certificate (if applicable) 15. Copy of Gazette for change in Name (if applicable) 16. SSC Mark sheet 17. HSC Passing Certificate 18. Copy of Preference Form 19. Birth Certificate 20. Copy of Aadhar Card 21. Undertaking for Ragging by student on plain paper (As per format attached) 22. Undertaking for Ragging by parents on plain paper (As per format attached) 23. Pass Port size Photograph (02 No.) Note: Submit attested xerox copies of above sr.no.1 to 20 only in three sets
ACADEMIC FEES I YEAR BDS ACADEMIC YEAR 2017-18 Merit Quota Mgt / NRI Quota (5x312000) Tuition Fees 3,12,000 15,60,000 D.D. No. 1 Library 1,000 1,000 Gymkhana 500 500 In the Name of Administration 1,500 1,500 DEAN, TERNA DENTAL COLLEGE, Student Association 1,000 1,000 NERUL, NAVI MUMBAI Deposit (Refundable) 10,000 10,000 Total Fees 3,26,000 15,74,000 ACADEMIC FEES Fee details of 85 % quota (Category wise) Open OBC SC & ST NT, VJ & SBC Tuition Fees 3,12,000 1,67,556 -- 23,111 Library 1,000 1,000 1,000 1,000 Gymkhana 500 500 500 500 Administration 1,500 1,500 1,500 1,500 Student Association 1,000 1,000 1,000 1,000 Deposit (Refundable) 10,000 10,000 10,000 10,000 Total Fees 3,26,000 1,81,556 14,000 37,111 D.D. No. 1 In the Name of DEAN, TERNA DENTAL COLLEGE, NERUL, NAVI MUMBAI
HOSTEL FEE HOSTEL FEES 60,000 D.D. No. 2 Deposit (Refundable) 15,000 Total 75,000 Rs.75,000/- In the Name of TERNA PUBLIC CHARITABLE TRUST, NERUL, NAVI MUMBAI. MUHS ELIGIBILITY FEE MUHS Eligibility & Other Fee Open 7,560 D.D. No. 3 Category 2,720 DEAN, TERNA DENTAL COLLEGE, NERUL, NAVI MUMBAI AMARTYA SIKSHA YOJANA POLICY NATIONAL INSURANCE Rs. 2,125 D.D. No. 4 * Please make separate 04 D.D s as mentioned above names. Rs. 2,125/- In the Name of NATIONAL INSURANCE COMPANY LTD PAYABLE AT KOLHAPUR
ON PLAIN PAPER ANNEXURE I UNDERTAKING BY THE STUDENT 1) I s/o d/o Mr./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:
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:
ADMISSION TIMINGS KINDLY NOTE THAT THE ADMISSION PROCESS WILL BE CARRIED OUT DURING THE FOLLOWING TIMES: ADMISSION CELL WORKING HOURS 9 A.M. TO 3 P.M. MONDAY TO SATURDAY. BY ORDER