Form No.

___________
APPLICATION FORM
B.Sc. (MT) Radiography Course
Affix one recent UNIVERSITY COLLEGE OF MEDICAL SCIENCES
Photograph here duly G.T.B. HOSPITAL, DELHI- 110095
attested on the front (SESSION : 2017-18)
side by a Gazetted
Officer/ Principal of a
Recognized College/
Instt.
(for office use)
Please read instructions in the Prospectus carefully before you start to fill up the application form in your
hand-writing.

1. Name of the Candidate (In BLOCK letter) : ………………………………………………………………………………………………

2. Date of Birth : Day Month Year
3. Age as on 31.12.2017 (Must have completed 17 years.) _______________________
4. Gender (Tick) : Male Female Others
5. Marital Status : Married Unmarried
6. Nationality: ……………………………………
7. Email address: …………………………………………………………………………………………………………………………….
8. Mobile No. of the Candidate: ………………………….………. Land line No. ……….…………………………………
9. Do you belong to General Category? Yes No
10. Do you belong to Scheduled Caste? Yes No (if yes, attach copy)

11. Do you belong to Scheduled Tribe? Yes No (if yes, attach copy)

12. Do you belong to OBC ? Yes No (if yes, attach copy)

13. Do you belong to Person with disability (PWD)? Yes No (if yes, attach copy)
14. In-Service Candidate Yes No (if yes, attach proof)

Aggregate percentage of marks obtained in the qualifying exam. : ……………………… % (Result declared/
yet to be declared)
15. (a) Father’s or Guardian’s Name (In Block Letters): …………………………….…… Occupation: ………….…………………….
Email address …………………………………………………….. Mobile No. …….…………………………………………….
(b) Mother’s Name (In Block Letters): ……………..………………………………………… Occupation …………..……….………….
Email address …………………………………………………….. Mobile No. …….…………………………………………….
(c) Relationship (in case of Guardian) : ……………………………………………………………………………………………..
(d) Annual Income (Rs.): …………………………………………………………………………………………………………………..
(e) His/her permanent address & Telephone No./Mobile No. (if any ) : ………………………………………......
…………………………………………………………………………………………………………………………………………………….
16. Details of Examinations Passed or appearing for:
Year & Marks Div. if any
Name of the Roll No.
Examination passed month of Obtained with total Remarks,
Sch./ Coll. & at the In The Exam.
(or appearing) passing or Phy. Chem.Bio.Eng %age of If any
board exam
appearing (PCBE) marks
Matriculation
SSE/ Higher
Sec./Pre-University
10+2 system
or equivalent, specify
Any other exam. such as
10+2 in X-ray, or
Certificate/2 yr. Diploma
in X-ray Tech.

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17. University Enrolment No. : ……………………..
(If issued earlier by University of Delhi, in case the candidate has earlier passed any course from the University).

N.B. (i) In case of 10+2 system, the, Board/University and Roll No. must be mentioned.
(ii) If there is a break in the studies, if should be clearly mentioned, giving reason (s) for the interruption of the studies in
the remarks column or the space below.
(iii) Attach attested true copy of the mark sheet.
18. Address for correspondence (in full) including PIN code to which reply regarding this application may be sent (with
Telephone No.) if any
…………………………………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………………………………………………….

DECLARATION BY THE CANDIDATE

I __________________________________________ hereby declare that the application form has been filled in
my own handwriting and that the information given by me in the above application form is correct. I further declare that I
have read the rules as given in the Prospectus. I shall abide by the rules and regulations of the College and University of
Delhi.

Place
Date Signature of the applicant
Name:________________________

DECLARATION BY THE PARENT OF THE CANDIDATE OR THE GUARDIAN OF THE CANDIDATE IN CASE
NEITHER OF THE PARENTS IS ALIVE
I ___________________________________________ hereby solemnly affirm and declare that the information
furnished by the candidate is correct and nothing has been concealed. In the event that any false information has been
furnished or that there has been suppression of any factual information in the application form, or comes to notice of the
Institute authorities at any time during the course, he/she would be liable to be terminated besides other action by the
Institute as may be deemed fit.

I further declare that I hold myself responsible for the timely payment of all dues, i.e. tuition fee, fines and other
charges payable to the University College of Medical Sciences in respect of my son/ daughter/ ward during the period of
his/ her studies at the College and thereafter until the accounts are cleared.

Address:
Signature of the Parent/ Guardian
Name:________________________

Date :
DECLARATION BY THE SCHEDULED CASTE/TRIBE/OBC/PWD APPLICANT ONLY
I hereby declare that I belong to a Scheduled Caste/ Tribe/ OBC/ PWD category and that I desire admission to the
Institution under the special category for such candidate and I enclose herewith a Certificate from the prescribed
authority as proof of the same.

Enclosures:
1. ……………………………………………………………………………………………………………………………………………………………………………..
2. ……………………………………………………………………………………………………………………………………………………………………………..
3. ……………………………………………………………………………………………………………………………………………………………………………..
4. ……………………………………………………………………………………………………………………………………………………………………………..
5. ……………………………………………………………………………………………………………………………………………………………………………..
6. ……………………………………………………………………………………………………………………………………………………………………………..
7. ……………………………………………………………………………………………………………………………………………………………………………..

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PROFORMA FOR CERTIFICATION FROM THE PRINCIPAL OF
THE SCHOOL/COLLEGE LAST ATTENDED

1. Certified that Mr./Ms. …………………………………..………………………………………………………………………………………

S/o/D/o. ………………………………….……………………………………………………………………………………………………………….

has studied in (Name of the Course) …………………….………..……………………………………………………………… at

(Name and Address of the School/College) …………………………………………………………………………………………

………………………………………………………………………………….………………………………………………………………………………

from (mm/yy) ..………….………………….to (mm/yy) ……………………….…… (…………………………years).

2. Certified that Mr./Ms. ………………………….……………………………………………………………. has studied in this

School/College a regular student.

3. He/ She has appeared/passed ……………………………….……….…… examination under 10+2

system in (mm/yy) ……………………………………………………………….…………….. conducted by the

………………………………………….....……………………………………… (Name of the Board/University).

4. He/ She bears a good moral character.

5. This College is recognized by ………………………………………. (Name of the Board/University).

6. Date of Birth as per the Secondary School Certificate: ……………………………………………………

Date……………………… Signature of the Principal

and seal of the School/
College.

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Form No. ___________
ATTENDANCE SHEET
Admission to B.Sc. (MT) Radiography Course
Saturday, 10th June, 2017 Entrance Exam.
UNIVERSITY COLLEGE OF MEDICAL SCIENCES, DELHI-110 095.
(To be attached with the application form after affixing the photograph)

Reg. No. _________________

1. Name (in BLOCK letters) :…………………………………………………………………………………………………………..

2. Father’s Name : …..……………………………………………………………………………………………………………………
Affix one recent
Photograph here duly
attested on the front
side by a Gazetted
Officer/ Principal of a
Recognized School/
College/ Institution.

_______________________
(Signature of the Candidate)

Do not fill/or Sign below this line while submitting the application.

---------------------------------------------------------------------------------------------------------------------------------------
For use during examination
(For office use only)

________________________ __________________________
Signature of the candidate Signature of the Invigilator
at the time of examination (In case the candidate is absent
Invigilator may please write ABSENT
Date ……………………………… and put his signature.

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Form No. ___________
Admit Card
ENTRANCE EXAMINATION - B.Sc. (MT) RADIOGRAPHY COURSE 2017-18
Saturday, 10th June, 2017 at 11.00 A.M to 12.30 PM

To be completed by the candidate

Affix one recent
Photograph here duly
attested on the front Full signature of the candidate
side by a Gazetted (Signature with office stamp of
officer/ Principal of a the Gazetted officer attesting the
Recognized College/ Entrance Test- Date signature of the candidate)
Institution 10th June, 2017, For office use only
Centre ROLL NO.
College Block,
UCMS &.G.T.B. Hospital,
Dilshad Garden Delhi-95.

PLEASE READ THE FOLLOWING INSTRUCTIONS CAREFULLY.

1. You must present this admit card at Examination Centre for securing entry to the Examination Hall.
2. You must present yourself at the Examination Centre on 10th June, 2017 by 10:30 a.m.
3. You must read carefully the instructions printed overleaf.
4. In future correspondence, you must quote your Roll No.

IN CASE, YOU ARE FOUND ELIGIBLE FOR ADMISSION, YOU HAVE TO FULFIL THE FOLLOWING CONDITIONS:
(i) Submission of photographs.
(ii) Submission of attested true copy of the Matriculation/Secondary School Exam. Certificate issue by the University/
board showing your date of birth.
(iii) Submission of certificate of good conduct from Principal/Head of the Institution last attended.
(iv) Submission of attested true copy/ photocopy of certificate from the prescribed authority stating that you belong
to a Scheduled Caste/ Tribe/ OBC community. (In case, you belong to a Scheduled Caste/ Tribe/ OBC and you
have applied for admission against the reserved quota.
(v) Submission of documentary evidence of your having passed qualifying examination with the required percentage
of marks and subjects latest by 03rd June, 2017 falling which your performance at the Entrance Examination shall
not be considered.

To be filled by the candidate

Name: _______________________________
Father Name: __________________________
Address: ______________________________
_____________________________________
Tel.: _________________________________
State_____________ Pin Code____________ Section Officer (Acad.)
----------------------------------------------------------------------------------------------------------------------------------------------------------------
FOR OFFICE USE ONLY Form No.________________
UNIVERSITY COLLEGE OF MEDICAL SCIENCES
G.T.B. HOSPITAL, DELHI-110 095.

Received an application form from Mr./Ms. …………………………………………….….………S/o/D/o………….……….……..…………….…….

for admission to B.Sc. (MT) Radiography Course 2017.

Section Officer (Acad.)

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INSTRUCTIONS FOR THE CANDIDATES
Read the following instruction carefully.

DO’s
1. The candidate must bring the admit card (without the envelope) with him/her to secure admission to the
Examination hall (failing to do so, shall render him/her liable to expulsion. This shall be checked and verified during
the examination).
2. The candidate should bring his/her own fountain pen or black ball point pen for the examination.
3. The candidate must write his/her own Roll Number on the answer sheet in the space provided for it.
4. The candidate should sign the attendance sheet when directed to do so by the invigilator.
5. The candidate must observe silence in the Examination Hall (Any candidate found guilty of disorder or improper
conduct shall be liable to expulsion from the Examination Hall).
6. The candidate is under the disciplinary control of the Superintendent of Examination and required to obey his/her
instruction. The candidate who fails to observe these instructions shall be disqualified and debarred from appearing
in this and in any subsequent examination (s) to be held by the Institution.
7. The candidate should leave the room only after handing over his/her Test Booklet and Answer Sheet to the
Invigilator.

DONT’s
1. Do not bring any article other than specified in the instructions including the envelope in which admit card was
mailed to you.
2. Do not copy from the paper of any candidate or permit his/her own papers to be copied or attempt to give or obtain
irregular assistance of any kind.
3. No entry into the Examination Hall after beginning of entrance test.
4. Cannot leave the Examination Hall during the initial 90 minutes after distribution of the question paper.
5. Do not take away the question paper/answer sheet out of the Examination Hall.
6. Do not write/scribble or otherwise spoil the furniture and the admit card placed at your desk.
7. Do not carry any text material, printed or written, bits of papers, envelope in which admit card was dispatched or
any other material except the admit card, inside the examination hall.
8. Do not copy the questions and answers on the admit card.