For Office Use only

Transaction ID: 2312308/MBBS

ALIGARH MUSLIM UNIVERSITY Session: 2013-14 Application Form for Admission to M.B.B.S./B.D.S. FACULTY OF MEDICINE

Affix (don't staple) Self Attested Photograph of size 2.5 x 3cm

Bank: STATE BANK OF INDIA, DD/CR No.: 796772, Date: 2013-03-19, Amount: 500

Nationality: INDIAN

Order of Preference of Branches: __________________________________________________________________________________________________ 1. MBBS 2. BDSB 3. -- 4. -- 5. -- 6. -- 7. -- 8. -- 9. -Preference for Test Centres: __________________________________________________________________________________________________ 1. ALIGARH 2. LUCKNOW

Personal Details: __________________________________________________________________________________________________
Name: MOHSIN BEIG Date of Birth: 02-03-1996 Gender: MALE Religion: ISLAM Father's Name: KHALID BEIG Mother's Name: SHAHEEN BEIG Parent's/Guardian's Monthly Income: 20000 Rural/Urban: URBAN

Details of Qualifying Examination: Status & Special Categories: __________________________________________________________________________________________________
Examination: INTERMEDIATE Roll No.: Year of Passing/Appearing: 2013 Board/Univ.: 521 Marks Obt./Max. Marks: / Remarks (if any): RA Status: EXTERNAL Enrolment No.: Hall: Special Categories: 1. -- 2. -- 3. --

Course(s) Studied/Studying other than Qualifying Examination (Starting from the latest): __________________________________________________________________________________________________ Course Yr. of Passing/Appearing Board/Univ. Roll No.

HIGH SCHOOL

2011

521

5269023

Permanent Address: Address for Correspondence: __________________________________________________________________________________________________
Address: MOHALLA SEER GOTIYA BEHIND JAMA MASJID RUDRAPUR - 263153(UK) Phone 1: 8449287227 Phone 2: 8449287227 Address: MOHALLA SEER GOTIYA BEHIND JAMA MASJID RUDRAPUR - 263153(UK) Email ID: beigmohsin@yahoo.com

If admitted, is hostel accomodation required? YES __________________________________________________________________________________________________
DECLARATION: I SOLEMNLY UNDERTAKE to accept and abide by the rules of the Aligarh Muslim University and all the decisions of the Academic Council & other appropriate University bodies in regard to my admission. I hereby solemnly affirm that I have gone through the Guide to Admissions 2013-14 and solemnly declare on oath that the entries made by me in the above columns are true to the best of my knowledge and belief and if at any time, the entries are found incorrect, the admission may outrightly be cancelled and disciplinary action may be initiated against me. Transaction ID: 2312308/MBBS

19/03/2013-06:05

Thumb Impression Male: Left Thumb, Female: Right Thumb

__________________________ Signature of the Candidate

List of enclosures attached with the Application Form:

FOR OFFICE USE ONLY

1. 2. 3. 4. 5. 6. 7. 8.

DD/Cash Receipt in Original Self Attested copy of HS/SS Certificate in support of date of Birth Copies of Marksheets/Grade Sheets of all previous Examinations passed/appeared including parts therein after passing High School If employed, copy of No Objection Certificate from the employer Copy of documents in support of Special Categories clamied, if any Copy of document(s), if rusticated/debarred or convicted by a court of law ________________________________________ ________________________________________ Hall Allotted: Verifying Officer ____________________ Dept. of ___________________________ Date ____________________ Clearance by Proctor DSW Signature of Scrutiny Officer Identity & Original Documents Verified The candidate is eligible/not eligible for admission to ____________________________________ Remarks ____________________________

--------------------------------------------------------------------------------------------------------------------------------------Name: MOHSIN BEIG Name: MOHSIN BEIG Address: MOHALLA SEER GOTIYA Address: MOHALLA SEER GOTIYA BEHIND JAMA MASJID BEHIND JAMA MASJID RUDRAPUR - 263153(UK) RUDRAPUR - 263153(UK) Tel./Mobile: 8449287227 Tel./Mobile: 8449287227 ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Name: MOHSIN BEIG Name: MOHSIN BEIG Address: MOHALLA SEER GOTIYA Address: MOHALLA SEER GOTIYA BEHIND JAMA MASJID BEHIND JAMA MASJID RUDRAPUR - 263153(UK) RUDRAPUR - 263153(UK) Tel./Mobile: 8449287227 Tel./Mobile: 8449287227 --------------------------------------------------------------------------------------------------------------------------------------Aligarh Muslim University Scan Card, 2013-14 M.B.B.S./B.D.S.
(For Office Use only)

Address Slips (for Office Use):

Transaction ID: 2312308/MBBS

Affix (don't staple)

Name: MOHSIN BEIG Address: MOHALLA SEER GOTIYA BEHIND JAMA MASJID RUDRAPUR - 263153(UK) Tel./Mobile: 8449287227

NON-ATTESTED Photograph of size 2.5 x 3cm

Thumb Impression Male(Left Thumb)/Female(Right Thumb)
Specimen Signature of the candidate

ACKNOWLEDGEMENT SLIP, AMU, Aligarh
Application form for admission to: M.B.B.S./B.D.S., 2013-14 has been received. App. No. is: _____________________ Transaction ID: 2312308/MBBS To, Name: MOHSIN BEIG Address: MOHALLA SEER GOTIYA BEHIND JAMA MASJID RUDRAPUR - 263153(UK) Tel./Mobile: 8449287227

POSTAL SLIP
Application Form for Admission to M.B.B.S./B.D.S.

To, ASSTT./DY. CONTROLLER (ADMISSIONS) ADMISSION SECTION, AMU, ALIGARH - 202002 (UP)
From: Name: MOHSIN BEIG Address: MOHALLA SEER GOTIYA BEHIND JAMA MASJID RUDRAPUR - 263153(UK) Tel./Mobile: 8449287227

--------------------------------------------------------------------------------------------------Aligarh Muslim University CANDIDATE'S SLIP

(Keep this Slip with you for future reference) Course Applied for: M.B.B.S./B.D.S. Transaction ID: 2312308/MBBS Test Date: 26.5.2013 Password: 1996-03-02 _______________________________________________________________________________

INSTRUCTIONS
1. Please ensure that you have appended Photographs, Thumb Impression and Signature at the designated places on the Application form.
Note: a) Use identical good quality color photographs taken not earlier than 3 months. The photographs should be taken preferably wearing dark clothes on a white background. b) Your Thumb Impression & Signature establish your identity hence, do not merely write your name in capital letters.

2. You must Ensure that all the documents along with Demand Draft/Cash Receipt is attached with the Application Form.
Note: Demand Draft (valid for 3 months) of the requisite amount should be drawn in favor of FINANCE OFFICER, AMU, payable at Aligarh.

3. You must NOT make any type of correction(s) / modification(s) on the Application Form else your candidature may be rejected. 4. Paste the ‘POSTAL SLIP’ given above on the A-4 size Envelope containing the Application Form and send it on the Pre-Printed Address. 5. Please be a regular visitor to our website: www.amucontrollerexams.com which will provide you with necessary updates regarding the status of your Application Form/Admission Test results etc.