Post on 22-Mar-2018
First MBBS Admission 2016-17
Requirements at time of reporting to the college
1 Pass Port size photo – 04
2 All Original Certificates Below
1. Allotment Letter (CET/AIQ)
2. SSLC Marks Card (10th)
3. PUC Marks Card (10 + 2)
4. T.C. + Study Certificate
Caste Certificate, Income Certificate
( Cat I/IIa/IIb/IIIa/IIIb/SC/ST)
5. Physical Fitness Certificate With Blood Groups
(Any Govt. Hospital)
6. Eligible Certificate/ Migration Certificate (All India Quota/CBSE) From
RGUHS, Bangaluru.
7. CET & PMT (AIQ) Marks (Net Copy)
8. Total 3 Sets Xerox Copies Of All Certificates.
(Candidates Should Maintain Adequate Number Of Xerox Sets Of All
Documents For Themselves Separately.)
3 E – Stamp Bonds – Total 04, details of which uploaded on website.
College fees structure 1. CET General Candidate – Rs 8,375
2. CET SC/ST/CAT-I Candidates –Rs 15,875
3. AIQ- Rs 25,075
Kindly go through the Admission form which has been uploaded on website-
www.kimskodagu.kar.nic.in
-sd-
Director and Dean
Kodagu Institute of Medical Sciences
Madikeri
No: KoIMS/UGC(1) 001 /2016-17 Dated: 04-07-2016
Under Graduates 1st year MBBS Fees structure 2016-17
Sl. No Particulars 1st Year
Admission
AIQ
1st Year
Admission
SC/ST
Other Category
CET 1st Year
Admission
College Fees
(CET)
1. Tuition Fee 9200 9200
2. Helinet 4600 4600 4600
3. Registration 3000 3000 2500 1000
4. Admission 500 500 500
5. SWF (41/2 Yrs) 450 450 150 300
6. Sports (41/2 Yrs) 1125 1125 150 975
7. Admission 400 400 400
8. CET Fees 500 500
9. ID 100 100 100
10. Student Association 500 500 500
11. Sports 500 500 250 250
12. Library 1500 1500 1500
13. Magazine 300 300 150 150
14. Lab 500 500 500
15. Med. Exam 150 150 150
16. Caution 1000 1000 1000
17. Alumini 750 750 750
Total 25075 15875 16700 8375
To be paid into Ac No- 64199775815
Name: KoIMS Student FEE ACCOUNT
Branch: SBM, Madikeri Branch
-sd-
Director and Dean
Kodagu Institute of Medical Sciences
Madikeri
Admission Form
(Details to be entered in block letters only)
SEAT ALOTTMENT No.:
1 Name (As mentioned in SSLC / 10th
Standard)
2 Gender
3 Date of Birth
3 Father Name
4 Mother Name
5 Permanent Address
Communication Address:
(Phone number and email)
6 Nationality 7 Religion
8 Caste & category
9 Mother tongue 10 Seat type 11 All India Rank 12 CET Rank
13 Qualifying Exam (II PUC / 12th
)
14 Registration No of Qualifying Exam
(II PUC / 12th
)
Recent passport size photo with self attestation
15 Year of passing 16 University/Board
17 Optional Subjects( PUC marks) Max Marks Marks Secured
Physics Chemistry Biology Mathematics English
Kannada / Hindi
PCB Total 18 Entrance Hall Ticket No 20 Entrance Marks (along with Max.
Marks)
21 Entrance Percentage 22 CET Entrance Rank 23 Date of Admission
24 Blood group 25 State & Native District 26 Urban/Rural 27 Annual Income 28 In case of emergency, contact
details
28 Remarks
DECLARATION
All the entries made above are true to best of my knowledge and I am directly responsible
for any fallacies
Signature of the Student Signature of the Parent or Guardian
Verifying Officer & Designation:
Place:
Date:
I MBBS ADMISSION CHECKLIST
(Three Sets of Attested Photocopies need to be submitted)
Sl.
No
Type of Documents Submitted
(Yes/No)
Remarks
1. Recent Passport photos (4 Nos.)
2. Copy of Fees Paid At Allotment
Centre
3. Copy of Fees Paid At KoIMS,
Madikeri
4. CET/AIPMT admission ticket
5. KET/ AIPMT Admission Order
6. Seat allotment number
7. Entrance examination Marks
Statement
8. SSLC/10th Standard Marks Statement
9. PUC/12th Standard Marks Statement
10. Eligibility Certificate( 10+2 students)
11. Caste Certificate(SC & ST students
should produce caste Certificate in
English Only)
12. Transfer Certificate(10+2)
13. Study Certificate ( for 12th year)
14. Kannada Medium/Rural Study
Certificate
15. 371 J Eligibility Certificate if
applicable.
16. Affidavit for MBBS admission
17. Affidavit for Anti-ragging( by student)
18. Affidavit for Anti-ragging( by Parent)
19. Affidavit for Rural service after
completion of MBBS
20. Physical Fitness Certificate
DECLARATION
Photo Copies of all documents submitted for MBBS admissions are true and correct to the
best of my knowledge. I also accept that my admission to I MBBS Course at this institution
is provisional and subject to approval from RGUHS, Bangalore, Karnataka and MCI, New
Delhi.
Place: Signature of Student
Date:
FILE FOLDER NO.
SEAT
ALLOTMENT
NUMBER
SEAT TYPE
STUDENT’S NAME
FATHER’S NAME
DOB
AGE
DATE OF
ADMISSION
CONTACT
NUMBER
AFFIDAVIT- I
Bond value: Rs. 50/- e-stamp/bond;
1st Party: Parents’ name 2nd Party: Govt. of Karnataka
UNDERTAKING MBBS DEGREE PROGRAMME AS PER RGUHS CURRICULUM
I_____________________________________________________ Son / Daughter of
______________________________________ (herein after called the Natural Guardian of the
Student) hereby given an undertaking that on admission to I MBBS at KODAGU INSTITUTE
OF MEDICAL SCIENCES, MADIKERI, KODAGU DISTRICT, during the year 2016-17, read
the rule No.11of the ordinance of Governing M.B.B.S. Degree Programme of Rajiv Gandhi
University of Health Sciences, Bangalore, vide Notification No. ACA/BOS-27/97-98, dated:
24.03.1998, and I shall abide / by the ordinance. That no student shall be permitted to join Phase-
II (Para Clinical & Clinical) Group of subjects until he / she passes in the Phase-I (pre-clinical)
subject for which he / she will be permitted not more than four chances (Actual Examination)
provided four chances are completed within three years from the date of enrolment.
Signature of the Parents with full address
Witness: 1)
2)
SEAL & SIGNATURE OF NOTARY
AFFIDAVIT –II- BY THE STUDENT
Anti ragging concern- Proforma
Bond value: Rs. 20/- e-stamp/bond;
1st Party: Student’s name 2nd Party: KoIMS, Madikeri.
1. I, _____________________________ (full name of the student
with admission/registration/enrolment number) s/o d/o Mr./Mrs./Ms.
____________________ having been admitted to __________________________ (name of
the institution), 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 understand 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 or 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 behavior or act that may be constituted as ragging under clause 3 of the Regulations. b) I
will no participate in or abet or propagate through any act of commission or omission that
may be constituted as tagging 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:
Address:
Mobile No. :
VERIFICATION
Verified that the contents of this affidavit are true to the best of my knowledge and no part of
the affidavit is false and nothing has been concealed or misstated therein. Verified at
_______________ (place) this ___________ (day) of ______________________ (month),
________________________ (year). _______________________
Signature of deponent
Solemnly affirmed and signed in my presence on this the
______________________________ (day) of ___________________ (month),
_______________________ (year) after reading the contents of this affidavit.
OATH COMMISSIONER
AFFIDAVIT –III- BY THE PARENT/ GUARDIAN
Anti ragging concern- Proforma
Bond value: Rs. 20/- e-stamp/bond;
1st Party: Parent’s/ Guardian’s Name 2nd Party: KoIMS, Madikeri.
1. I,
Mr./Mrs./Ms.__________________________________________ (full name of
parent /guardian /father /mother /guardian of, _____________________ (full name of
student with admission/registration/enrolment number), having been admitted to
__________________________ (name of the institution), 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
understand 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 or 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 behavior or act that may be constituted as ragging under clause 3 of the
Regulations. b) I will no participate in or abet or propagate through any act of
commission or omission that may be constituted as tagging 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:
Address:
Mobile No. :
VERIFICATION
Verified that the contents of this affidavit are true to the best of my knowledge and no
part of the affidavit is false and nothing has been concealed or missstated therein.
Verified at _______________ (place) this ___________ (day) of
______________________ (month), ________________________ (year).
Signature of deponent
Solemnly affirmed and signed in my presence on this the __________ (day) of
________________ (month), _______________________ (year) after reading the
contents of this affidavit.
OATH COMMISSIONER
AFFIDAVIT –IV
Rural service for MBBS students
Bond value: Rs. 100/- e-stamp/bond
1st Party: Student’s Name 2nd Party: Government of Karnataka
I,MR . / Kum
………………………………………………………………………………………………… S/o.
/ D/o………………….…………………………………………… a candidate with ‘CET–2016’
Admission Ticket No…………………… residing at
……….…………………………………………………………………………….
………………………………………………………………………………………………………
…………………………………
………………………………………………………………………………………………………
………………………………… have on my own volition allotted a MBBS seat on
…………..…………………............................... In
……………………………………………………………….vide admission order number
…………………………............... dated ………………….... and do hereby undertake as
follows:
In accordance with the Amendment to Rule 11 of the Karnataka Selection of Candidates for
Admission to Governmen t seats in Professional Educational Institutions Rules, 2006, vide
Government Notification – 1. No.HFW 79 RGU 2011 dated 17-07-2012, I am prepared on
completion of the course to serve in any Primary Health Center or Primary Health Unit situated
in Rural Areas in the State of Karnataka for a minimum period of ONE year, failing which I
render myself liable to pay a penalty of Rupees Ten Lakhs to Government of Karnataka.
What is stated above is true and correct and I and my parent hereby undertake to act accordingly.
Signature of the candidate Signature of the Parent
(Father / Mother)
Date:……………………..
Place:......................