APPLICATION FORM FOR DM (Medical Oncology)

1
APPLICATION FORM FOR
D.M. (Medical Oncology) / M.Ch. (SURGICAL ONCOLOGY)
2014
CANCER INSTITUTE (WIA), CHENNAI
1.
Candidates name in full with expanded initials
(IN BLOCK LETTERS)
Name of the candidate should be underlined
2a.
Address for correspondence
2b.
Permanent Address with Area Code
2c.
Phone (with STD code)
Mobile
E-mail
3
Nationality to which the candidate belongs
4
a) Present occupation of the candidate
(Evidence should be produced)
b) Please clarify whether the above service is
Government / Quasi-government / Defense
/ Public sector / Private
5
Name and occupation of Father/Mother &
Spouse, if married, with address
6
Does the candidate belong to the scheduled caste
or the scheduled tribe or other socially and
educationally backward classes specified in the
Tamil Nadu Education Rules?
(Certificate to be furnished)
7
Age and date of birth (Evidence to be produced)
8.
Mother Tongue
Signed
photograph to
be pasted
2
9
Qualification
Year & Month of
passing
No. of attempts
/ Class
College
University
MBBS
MD / MS
Others
(Copies of the certificates for the above qualifications to be enclosed)
10
Marks obtained in MD/ MS / DNB examinations
(Copies of mark sheets must be attached)
11
Prizes, Medals & Merit certificates awarded by the
University/College in the M.B.B.S/ M.D. /M.S./ DNB
courses
(Copies of the certificates to be enclosed)
12
a)
b)
No. of Publications (Copies of reprints to be
attached) (please attach separate sheet listing all
publications)
Research work done, if any (Copy of
certificate to be attached)
13
Distinction in sports (Copy of certificate to be attached)
14
Extracurricular activities - Music, social service etc.
(Copies of the certificates to be enclosed)
15
Nature of work done subsequent to passing
M.B.B.S.& M.D. / M.S./ DNB (Copies of certificates to be
attached)
16
a) Addiction to smoking, alcohol or drugs
b) Are you suffering from Mental health issues
c) Handicaps, if any
d) Treatment for any serious / chronic medical
illness
17
Permanent registration number with State Medical
Council or Medical Council of India (Copy to be
enclosed)
18
Bank Name, Number and date of Demand Draft
attached
19
One signed passport size photograph to be pasted
in the space provided. Two more photographs are
to be enclosed
20
Conduct Certificates (two)
PLACE :
DATE
:
SIGNATURE OF THE CANDIDATE
Reg. No.
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DECLARATION BY CANDIDATE
I,
do hereby solemnly and
sincerely affirm that the statement made and information furnished in my
application form as also in all the enclosures thereto submitted by me are true.
Should it how ever be found that the information furnished therein is untrue in
material particulars, I realize that I am liable for criminal prosecution and I also
agree to forego my seat for the course at any stage.
Station
:
Date
:
Signature of the Candidate
Check list
Please tick if the following documents have been enclosed in order
Yes
1
MBBS degree certificate
2
MD/MS/DNB degree certificate
3
Medical Council Registration (National/State)
4
Age proof certificate
5
SC/ST/other backward class certificate
6
MD/MS/DNB mark sheet
7
List of publications
8
Research work done
9
Certificates mentioned in serial 11
10
Certificates mentioned in serial 13
11
Certificates mentioned in serial 14
12
Certificates mentioned in serial 15
13
Demand draft
14
2 passport size photos
15
Two conduct certificates
16
Evidence of Nationality
No
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PROSPECTUS
GENERAL INSTRUCTIONS:
1. Candidates applying for the DM. (Medical Oncology) / M.Ch. (Surgical oncology) at the
Institute should have passed the following appropriate qualifying examination of the
Tamilnadu Dr.M.G.R.Medical University or any other equivalent Indian University
recognised by the Medical Council of India.
M.Ch (Surgical Oncology)
M.S. / DNB (Gen.Surgery)
M.D. (Obstetrics & Gynaecology)
M.S. (ENT)
M.S. (Orthopaedics)
DM (Medical Oncology)
DNB/MD (General Medicine)
DNB/MD (Radiotherapy)
DNB/MD (Pediatrics)
Candidates who have written their examination and awaiting the results are not
eligible to apply
2. In case of Government / Quasi-government / Defense / Public sector Service candidates
and candidates being deputed by an institution/organization, the application should
necessarily be made through the relevant proper channel, failing which the application
will not be considered. Advance copies will not entitle them to be called for entrance
examination. They should produce at the time of interview a no objection certificate
affirming that the candidates will be released for the course if and when selected.
3. All the entries in the application form must be legibly written by the candidates in
his/her own handwriting.
4a. An Account Payee Demand Draft dated not earlier than 01st April, 2014 drawn in
favour of the Cancer Institute (WIA), Chennai – 20, for Rs.5000/- (Rupees Five thousand
only) towards Registration fee, should be attached to each application. This fee will not
be refunded under any circumstance, whether the candidate is called for the entrance
examination or not. Candidates are, therefore, advised to satisfy themselves before
applying that they fulfill all the conditions as per regulations.
4b. Candidate to provide a self-addressed, stamped envelope along with the application.
5. No document produced along with the application will be returned and only Xerox
copies of certificates should be enclosed with the application form. The application of
the candidates will be considered only when all the certificates are in order. The
original certificates should be produced at the time of interview for verification. The
original certificates once deposited on admission can not and will not be released to
them until they are considered to be no longer required by the Institute. Every
application with all enclosures securely fastened should be sent addressed to the
DIRECTOR & DEAN, CANCER INSTITUTE (WIA), EAST CANAL BANK ROAD, GANDHI
NAGAR, ADYAR, CHENNAI – 600 020, Tamil Nadu. Kindly mention on the top of the
envelope “Application for DM/M.Ch Examination 2014” The last date for the receipt
of duly filled applications to the office of the Cancer Institute (WIA) is 24 May 2014,
5.00 PM by courier or speed post.
NOTE: Incomplete applications and applications received after the due date and time
will be rejected summarily.
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6. Candidates whose applications are found to be in order will be sent an entrance
examination card indicating the time and date. There will be a theory examination (MCQ
pattern) and shortlisted candidates will be eligible for viva voce examination on the
same day. Further shortlisted candidates will undergo clinical examination on the same
day or the next day depending on time availability. Candidates should be prepared to
come for the exam/interview at their own expense. No accommodation facility will
be made by the Institute.
7. In the matter of selection, the decision of the selection committee shall be final and no
appeal shall be entertained on the subject.
8. Selected candidates should pay a caution deposit of Rs.10,000/- (Rupees Ten thousand
only) towards the recovery of the cost of broken instruments, lost library books etc.
which will be refunded to the candidate at the end of the course after due deduction.
9. Admission to the course is provisional, subject to the approval of the qualification of the
individual candidates by The Tamil Nadu Dr.M.G.R. Medical University. It is the
responsibility of the candidates to obtain the eligibility certificate from the university
prior to joining the course. All candidates provisionally selected shall also be subject to
a medical examination prior to final confirmation of selection.
10. Twin sharing bachelor’s accommodation is available in the hospital campus and will be
allotted on written request as per first-cum-first serve basis and as per availability of the
rooms. Students staying in the hostel will have to pay Rs.1250/- per month for the
services provided in the quarters.
11. All students will pay the annual fees to be paid from time to time to the Tamil Nadu
Dr.M.G.R.Medical University, such as the University administrative expense fee
(currently Rs.7500/-), Registration fee (currently Rs.11,200/-), Examination fee, fees for
inspection and continuation of provisional affiliation and Institute Administrative fee
(currently Rs.26,000/-)
12. All the candidates are required to do compulsory in-services at the Institute, after
successful completion of the course for the period of one year.
13. All candidates will sign a contract to complete the three years of study once they join the
course. Candidates will be paid Rs.25,000/- (Rupees Twenty Five thousand only) per
month as a consolidated stipend during the study period. Students will execute a bank
guarantee of Rs.5,00,000/- (Rupees Five lakh only) for 4 years. At the end of the
respective period, the bank guarantee will be released. Any breach of contract will entail
invoking of the bank guarantee.
14. Intimation will be sent to the selected candidates in time before the commencement of
the course and they should be prepared to join the course immediately on receiving the
information of selection.
15. The Final exam conducted by the Dr. MGR Medical University leading to the award of the
DM. / M.Ch degree is likely to be held in the first week of August. This may however
change depending on the rules of the university.
DIRECTOR & DEAN
COLLEGE OF ONCOLOGICAL SCIENCES
CANCER INSTITUTE (WIA)
CHENNAI – 600 020
CANCER INSTITUTE (WIA), CHENNAI
Photograph to
be pasted
DM./ M.Ch Entrance Examination Admit Card
Name & Address:
Venue
: Auditorium, Cancer Institute (WIA)
Dr.S.Krishnamurthy campus
No.38, Sardar Patel Road (Next to IIT)
Guindy, Chennai – 600036
FOR OFFICE USE ONLY
Date of the Examination:
Time
:
Kindly report 1 hour prior to the prescribed time of examination.
Please bring this admit card when you appear for the examination.
Candidates who do not produce admit card will not be allowed to take the exam.
Director & Dean
_____________________________________________________________________________________________