APPLICATION FORM
ADMISSION TO POST GRADUATE M.PHARM DEGREE COURSES IN TAMILNADU
GOVERNMENT / SELF FINANCING INSTITUTIONS 2010-2011
(UNDER THE PURVIEW OF THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY)
1.
Entrance  Examination  Number (will be assigned by the Selection Committee Office)2.
Registration  No. (A.R. No.) (To be filled in  by  the office)
3.
Name  (in capital
:
letters with initials at the end)4.Sex :  1. Male        2. Female 5..
Community
:
1. OC
2. BC  2A. BCM
3. MBC/DC
4. SC  4A. SCA
5.ST
6.Sub-caste
:7.Date of Birth (DD/MM/YY):8.Place of Birth :9.
Nationality
:  1. Indian    2. Others 10.Nativity :  1. Tamil Nadu State    2. Other 11.Mother Tongue
:
1. Tamil
2. Other
12.  (a)Permanent  Registration Number
of the B.Pharm  Degree issued by :
the Tamilnadu State Pharmacy Council
(b) Date of passing B.Pharmacy
:
Affix Passport
Size Photograph
with Name & Date duly attested by a
Gazetted Officer
Form  No.
13.Mailing address
Pincode
Phone Number - Residence No.:  1.
with STD Code
Mobile No.:  2.
14.Civic Status (Place of present:  1.  Corporation  2.  Municipality
Address)  3.  Township  4.  Major Panchayat
5. Minor Panchayat
6. Others
15.Qualifications
Duration College            Admission                  Passing Number of Name of the Degree of the from which Appearances University Course qualified Month Year Month    Year in the final Studied
(Years)Examination
B. Pharm
16 .Total Number of Completed
years of experience from the
last date of month of passing
B.Pharm as on 30-4-2010
17.Academic Marks Obtained in  B.Pharm
(For all subjects put-together)
Years Maximum Total Marks No. of
Marks Obtained          Attempts
Awarded
FIRST
SECOND
THIRD
FINAL
Grand Total
18.Are you applying for Differently Abled:Yes / No
(Physically Disabled) Category
19.SERVICE  PARTICUALRS (Applicable
for service candidates only)
A.Service:Yes / No
B.Service Details:        1.State Government
2.Local Bodies in Tamil Nadu
C.Service Status:        1.Temporary
2.Approved Probationer
3.Permanent
D.Date of First  Appointment:
(DD / MM / YY)
E.CATEGORY      TOTAL NO. OF YEARS OF
SERVICE as on 30-4-2010
Government Service
Private
F.Present Occupation:
G.Have you served in Hilly Region?
If so duration of service in Hilly
region (Refer Annexture V & VI)
20.Are there any Criminal proceedings /:
Enquiry or disciplinary proceedings
pending or contemplated against  you
Place :
Date  :
.....................................................................
SIGNATURE OF THE CANDIDATE
DECLARATION BY THE CANDIDATE
I
I _____________________________________________________________________________do hereby solemnly and sincerely affirm that the statements made and information furnished in my application form as also in all the enclosures thereto submitted by me are true. Should it however be fo
und that any information furnished therein is untrue in particulars, I realise that I am liable for criminal prosecution and agree to forego my seat in the College at any stage.
Station : ____________________
Date  : ____________________      Signature of the candidate
II
I declare that I have not acquired any Post Graduate M.Pharm Degree or Discontinued any Post Graduate M.Pharm  Degree Course on or after 30-04-2008, nor am I  undergoing any Post Graduate M.Pharm Degree Course at the time of submission of my application.
Station : ____________________
Date  : ____________________      Signature of the candidate
III - DECLARATION OF NATIVITY
I, Thiru / Selvi / Tmt. _________________________________________________________________
____ _______________________________ S/o. D/o. W/o. Thiru __________________________________________ _____________________________________________________________________________________________ an applicant for admission to Post Graduate M.Pham  Degree Course 2010-2011 session is a native of Tamil Nadu, and I solemnly declare that I am not claiming nativity in any other State.  I am providing the nativity certificate issued by Tahsildar / I am enclosing my educational certificates for the proof that I am domiciliary in Tamil Nadu for 5 years.
Signature of the Parent/Guardian          Signature of Candidate.
Note:-Claims for dual nativity / false nativity if found at any time after selection will result in expulsion from the course.
SERVICE CERTIFICATE
The service particulars of Thiru / Selvi / Tmt _____________________________________________________ S/o. D/o. W/o. Thiru _____________________________________________________ an applicant for admission to Post Graduate M.Pharm Degree Course for 2010-2011 Session is hereby furnished.
1.Present Post held:
2.Service Status (  Appropriate Answer)
Approved
Temporary Probationer Permanent.
3.Date of First Appointment:
4.Details of posts held and places of service:
including leave particulars.
POST HELD  PLACE DURATION
FROM TO
(If space is not sufficient, the above particulars may be furnished on a separate sheet with the signaturetruncated form
and seal of the forwarding authority)
4a.Duration of Service as on 30-04-2010:
4b.Whether the candidate has completed:
2 years of continuous service as on
30-4-2010 (excluding leave period)
5.Has the candidate served in Hilly region?:
If so, the duration of service in Hilly region
as on 30-4-2010
6.Is there any criminal proceedings, Enquiry:
or disciplinary proceedings  pending or
contemplated against the candidate.
Station  : ____________________
Date      : ____________________Signature of forwarding authority :
Designation / Office Seal:
Fax No.:
Note :  i.  All Service candidates should obtain the service certificates from the competent authority. Applicants without Service particulars duly authenticated by the competent authority are liable to be rejected.
ii.The above particulars should be verified scrupulously & in the event of any misinformation found later, the forwarding officer will be held responsible.

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