HEADQUARTERS. OFFICEEMPLOYEES' STATE INSURANCE

CORPORATIONPANCHDEEPBHAVAN: c.I.G. ROAD: NEWDELHI-110002 (ISO 9001-2000 Certified)

Website - www.esic.nic.in

DMC(ME)Fax: 011-23234537

Tele/Fax: 011-23234685

E-Mail:dmc-dl@esic.nic.in

VOIP No: 10011079

NO:L-ll/12/3/ UGAdmission /2014-15/MEC Date: 13/8/14

ADMISSION NOTICEINVITATION OF APPLICATIONS FOR ADMISSION OF 'WARDS OF

INSURED PERSONS' (IPs) IN UG COURSE (MBBS) IN ESIC MEDICALCOLLEGES FOR ACADEMIC SESSION 2014-15.

ESI Corporation, a statutory body established by an Act of Parliament,i.e. ESI Act [Act No. 34] of 1948, under the administrative control of

Ministry of Labour & Employment, Govt. of India, is in the process ofsetting up Medical Education Institutions leading to augmentation ofMedical, Dental, Nursing, Allied Health- Education institutions in thecountry at large.

The Central Government has approved the admission policy and

procedure for under graduate (MBBSjBDS) Courses in ESIC MedicalEducation Institutions (Annexure-I). It provides for ESIC ManagementQuota after allocation to "All India Quota" and the "StateGovernment Quota".

Applications are invited from 'Wards of Insured persons' under ESIScheme who have qualified in 'All India Pre-MedicaI/Pre-DentalEntrance Test. 2014' (AIPMT - 2014) for admission to UG course(MBBS) in ESIC Medical Colleges under "ESIC Management Quota"for academic session 2014-15 as per admission policy and procedureapproved by the Central Government.

I"'C ~ ~\P.l-~ qJTWRP. ......•.....ubStte CorIent&Ma~m~nl.. .

~~ ~./ No ,s.-8.l: .~~ / [YcOO ... _._ •.•••. \3. ..\.a.' ..~!.~ .

Institution-wise details of seats to be allotted under "ESICMANAGEMENT QUQTA" are as under

SI. Name of ESI Medical College Total UR SC ST OBC PHNo No of @ @ @

Seats 15% 7.5% 27%1. Joka- Kolkata, West Bengal 52 26 08 04 14

2. Rajaji Nagar, Bangalore, Karnataka 45 24 06** 03 123. Gulbarga, Karnataka 45 23 07** 03 12 30/0*4. K.K. Nagar, Chennai, Tamil Nadu 20 10 03 01** 06

Total 162 83 24 11 44*3% seats are reserved for P.H. category with 'Horizontal Reservation' acrossall categories.**Rounding off to match the model roster of reservation on All India basis byopen competition

Mechanism for filling up of ESIC Management Quota

IIIII

.:. Available seats of "ESIC Management Quota" in various States will bepooled on 'All India Basis' and allotted, amongst the wards of Insuredpersons (IPs) .

•:. The 'guiding principles' for filling up of ESIC Management Quota will be

as under:-

• The ESIC Management Quota seats will be filled on merit cumpreference basis.

• Reservation policy of Central Government for SCjSTjOBCjPH etc. willbe followed for allotment of seats

• Candidates seeking admission under 'ESIC Management Quota' willhave to fulfill the following eligibilitv criteria:

• Minimum eligibility criteria for admission will be as per MCIregulations.

• The selection and admission to MBBS seats in any MedicalInstitution recognized for running MBBS Courses as per IndianMedical Council Act 1956 is subject to fulfilling the admission

criteria, eligibility, medical fitness and such other criteria as may

be prescribed by the Universities etc.

• In event of any difference in criteria of MeI and AffiliatingUniversity etc., the higher criteria will prevail.

• Applicants are advised to refer to the websites of the Affiliating

Universities, i.e. Rajiv Gandhi University of Health Sciences

(RGUHS) for ESIC colleges in Karnataka; West Bengal University

IIIIIIIII

IIIII

I

of Health Sciences (WBUHS) for ESIC colleges in West Bengal and

The Tamil Nadu Dr. MGR Medical University (TNMGRMU) for ESIC

colleges in Tamil Nadu, for further information.

Application must be accompanied by "Ward of Insured

Person" Certificate, issued by concerned Regional

Director ISRO I/C. [Annexure - II]

• Candidates will be allotted seats, based on their category and merit

•

cum preference of Institution, through a centralized counseling to be

conducted by ESIC in Delhi for the ESIC Management Quota as per

schedule provided.

• The venue and other details for the counseling will be posted on the

web-site in due course. Candidates are requested to check the

web-site regularly for further details.

HOW TO APPLY

Candidates may submit application in the prescribed format (Annexure - III)

with copies of required certificates and Affidavits (Annexure - IV) well in time

so as to reach ESIC Hqrs. Office latest by 5 pm on 1st September 2014.

ESIC will not be responsible for any postal delay.

The application may be sent to

Director General"Panchdeep Bhawan", ESI Corporation HQ Office,C.I.G. Marg, New Delhi-110002

The envelope may be marked as under

APPLICATION FOR ADMISSION OF 'WARDS OF INSURED PERSONS' (IPs)IN UG COURSE (MBBS) IN ESIC MEDICAL COLLEGES(2014-15).

KIND ATTN: Dy. Med. Comm. (ME-II)

To,Director General"Panchdeep Bhawan",ESI Corporation HQ Office, C.I.G. Marg,New Delhi-ll0002

From: XYZ

I

IIIIIII

Important dates in the process of admission are as given below:-(tentative)

1- Last date for receipt of Applications at ESIC HQ, New Up to 5 pm onDelhi 1stSeptember 2014

2- Display of Provisional List of eligible candidates 3rd September 2014called for counseling

3- 1st Counseling & Allocation of College & deposit of 10th& 11thSeptemberfee 2014

4- 2nd Counseling, if required 18thSeptember 2014

OTHER IMPORTANT INSTRUCTIONS

1. Fee structure Stipulation on annual basis:

Tuition FeeRs 24,OOO/-(Rs. Twenty four thousand only)per annum (provisional*)

University Charges As per Actual

College Secu rity Deposit Rs 5000/- (Five thousand only) per annum

(Refundable) i.e. chargeable annually

Hostel Charges To be decided separately

Hostel and Mess Security To be decided separately

Mess Charges As per actualNote: As the MBBS Course is 4 1/2 years Course, The tuition fee to be charged for the

final year will be half of the Annual Tuition Fee.

*The fee of Rs. 24,000/- is provisional as the fee structure is under

revision. The 'Fee Fixation Committee' of the State Government which decidesthe fee structure of Government and Private Medical Colleges/ CompetentAuthority would be approached for revision of fee. The fee would accordinglybe revised from 2014-15 based on the decision of the 'Fee Fixation Committee'/ Competent Authority. The student would have to give an 'Affidavit' as perAnnexure - V to deposit the difference in the revised fee amount, if any.

Demand Draft (DO) of Rs. 24000/- drawn in favor of 'ESI Fund AccountNo.1', payable at New Delhi, shall have to be deposited at thecounseling venue, immediately (on the same day) after allotment of seat.The amount shall be refunded after deduction of Rs.1000/- if the seat issurrendered within 03 days of allotment. The amount will be forfeited if thestudent who is allotted the seat does not join the course within thestipulated time, which would be mentioned in the 'Letter of Allotment' of

seat

There will be no capitation fee or profiteering in any form.

II

IIIIIIIIII

2. Counseling for Allotment2.1 Candidate should bring the following documents in original along

with self-attested copies for verification failing which they will not beallowed to participate in the counseling process2.1.1 Secondary School Certificate which must bear Date of Birth

or Birth Certificate.

2.1.2 Senior Secondary School certificate (+2). Provisional if final

has not been issued

2.1.3 Admit card for All India Pre-Medical/Pre Dental Entrance

Test - 2014 (AIPMT -2014)

2.1.4 Score card (AIPMT-2014) with Rank Position i.e. All India

Rank

2.1.5 'Ward of Insured Person' Certificate from Competent

Authority.

2.1.6 Affidavit regarding fee structure and Bond amount as per

Annexure - V

2.1.7 SCjST Certificate in prescribed format (Annexure - VI)

2.1.8 OBC Certificate in prescribed format (Annexure - VII)

2.1.9 Physically Handicapped Certificate from 'Appropriate

Authority' as specified by the concerned State/U'T

Government (Annexure - VIII) subject to verification by

Competent ESIC Board, if required.

2.1.10 For FEMALECANDIDATES ONLY

2.1.10.1 Affidavit by candidate as per Annexure - IX

2.1.10.2 Affidavit by IP as per Annexure - X

2.2 Option once exercised during counselling will be final and cannot be

changed.2.3 Candidates who fail to attend the counselling at the specified date

and time will forfeit their right to counselling and admission and their

name will not be considered later.

2.4 If the candidate is absent during the 1st phase of counselling for

which he / she is called, he / she will not be eligible to attend the 2nd

phase of Counselling

IIIIIII

I

3. Ref: Para 3 of Annexure - I - 'ESIC Management Quota' - Wards of

Insured Persons from anywhere in India are eligible to apply for these seatsand seats shall be allotted based on All India merit cum preference basis,following counseling by ESIC Selection committee constituted by CompetentAuthority.

4. Execution of Bond for Service - ref para 7 of Annexure - IThe amount to be paid to ESIC towards failure to fulfill obligation underBond is Rs. 7.5 lac. The amount is provisional and is likely to be revisedconsequent to the decision of the Competent Authority. The student wouldhave to give an 'Affidavit' as per Annexure - V to deposit the revised amount,if any, in event of failure to fulfill obligation under Bond.

IIIIIIIIIIIIIIII

5. Insured person for the purpose of availing benefit of ESIC ManagementQuota - ref para 8 of Annexure - I

6. 'Ward of Insured Person' - ref para 9 of Annexure - I

Oy. Med. Comm. (ME-II)For Director General

ANNEXURE-!

ADMISSION POLICY FOR UNDER GRADUATE (M88S/8DS) ADMISSIONS

IIIIIIIII

Admission procedure for under graduate courses (M88S and 8DS) in

ESIC Medical Education institutions shall be as follows:

1. All India Ouota: 'All India Quota' will be 15% of total available seats in

each of its Medical Institutions, Or, All India Quota will be as per the

prevailing Central Government's [i .e. Ministry of H & FW] directives for the

said quota, from time to time. It will be filled up as per policy, including

reservation policy, and procedures of the Central Government.

2. State Government Ouota: Based on the location of the ESI's Medical

Education Institution, a 'State Government Quota' will be as per the policy of

respective States applicable to un-aided non-minority Institutions, or in the

absence thereof, as may be mutually agreed to, between the respective State

Government and the ESI Corporation from time to time. The Admissions to

these seats will be made according to the policy, including reservation policy,

and procedures of the State Government concerned, and these seats will be

filled up accordingly.

3. 'ESIC Management Quota' The remaining seats after allocation to All India

Quota and the State Govt. Quota shall be treated as "ESIC Management

Quota". It shall comprise of seats 'pooled' together on All India basis from

various ESIC Medical/Dental Colleges, as the case may be. The seats shall be

allotted to the 'Wards of Insured Persons' (IPs) on All India basis and shall be

filled-up through merit cum preference basis, following due process specified

below or as may be specified by ESIC from time to time.

4. Methodology for filling up of ESIC Management Quota:-Available

seats of "ESIC Management Quota" in various States will be pooled on 'All

India Basis' and allotted, among the wards of Insured persons (IPs). The

'guiding principles' for filling up of ESIC Management will be as under:-

4.1 The ESIC Management Quota seats will be filled through merit cum

preference basis.

4.2 Reservation policy of the Central Government will be followed,

within the ESIC Management Quota enumerated above.

4.3 Candidates seeking admission under 'ESIC Management Quota' will

have to fulfill the following eligibilitv criteria:

4.3.1 Minimum eligibility criteria for admission will be as per MCI

regulations

4.3.2 Submit "Ward of Insured Person" certificate issued by

Competent/ desiqnated Authority for the purpose by ESIC.

4.4 Prospective/desirous and eligible candidates will be required to

appear in an All India competitive examinations in force or any

other similar equivalent approved Central entrance test as may be

specified from time to time by ESIC.

4.5 After qualifying in such Centralized test, candidates will have to

respond to the advertisement by the ESIC and, apply for

admission under the ESIC Management Quota, along with the

marks / merit obtained in the said Centralized Entrance Test, their

preference and supportive documents, etc.

4.6 ESIC will then prepare a merit list based on the rank /marks of

eligible applicants in the specified test/merit list for the year,

consistent with the reservation policy of the Central Government

for preparation of category-wise inter-se merit.

4.7 Candidates will be allotted the seats, based on their merit cum

preference of Institution and category, through a centralized

counseling to be conducted by ESIC for the ESIC Management

Quota.

5. Unfilled/Un-allotted seats, if any, after the specified cut-off date, will be

surrendered to the respective State Government as per the time schedule

given by the regulatory body, i.e. of Medical/Dental Council of India

(MCI/DCI), for inclusion in the State Government Quota, to be filled up as

per policy, including reservation policy, and procedures of the State

Government.

6. Fee structure Stipulation:

Fee structure (Tuition fee & other approved fee) in ESIC Medical Education

Institutions will be as may be approved by ESIC from time to time. There

will be no capitation fee or profiteering in any form.

7. Execution of Bond for Service

All Candidates seeking admission to any ESIC Medical Education

Institution will have to execute a bond, to serve any ESIC / ESI Scheme

(ESIS institution run by State Government) for a period of 5 years, as

may be specified, from time to time. Period of rural service. if any. as per

policy of the Central or State Government. will be inclusive in the five

year period of the bond.

8. Insured person for the purpose of availing benefit ESIC Management

Quota for his / her wards shall be, as under

''''The 'Insured Person' shall be an 'emplovee' as defined in the ESI Act: and

he/she should have been in continuous insurable emplovment for a period

of five vears as on 1st January of the year of admission and should have

paid at least 78 days of contribution in each contribution period, during

this five vear period."

9. 'Ward of Insured Person' will be a legitimate natural born child who is

wholly dependent on the earnings of the insured person and who is -

(i) receiving education, till he or she attains the age of twenty-one

III

years.

(ii) or an unmarried legitimate natural born daughter.

10. Regional Director/Other Officer/Authority/Committee under ESIC as may

be specified by ESIC from time to time shall be the Competent Authority

to issue the "Ward of Insured Person" certificate

Annexure - IIPhoto of Photo of IP

'Ward of IP' duly Attestedduly Attested by ROllO lIeby ROllO lIe'Ward of Insured Person' (IP)

CERTIFICATE(To be issued on OFFICIAL LETTERHEAO)

This is to certify that Son/Daughter/Ward of Shri/Smt Insurance No:___________ is 'Ward of Insured person' as per records.

Shri/Smt _ Insurance No: _ Son /Daughter /Village/Taluk

Wife of is a resident of_________ Distt State

_________ and has been in continuous insurable Employment of (Fulladdress of the Shop/Establishment with Employers Code No.) for aperiod of five years, as on 01/01/2014, and contributions have beenpaid for at least 78 days in each contribution period mentioned below,during this five year period as per record with details as under:

s. No. Contribution periods for academic session Contribution paid for -2014-15 No. of days

1. 1st April, 2009 - 30th September, 20092. 1st October, 2009 - 31st March, 20103. l" April, 2010 - so" September, 20104. 1st October, 2010 - 31st March, 20115. 1st April, 2011 - so" September, 20116. 1st October, 2011- 31st March, 20127. 1st April, 2012 - 30th September, 20128. 1st October, 2012 - 31st March, 20139. 1st April, 2013 - 30th September, 2013

This certificate is being issued on the basis of Verification of records by Shri/Smt.designation

_________ at Regional/SRO Officefor eligibility under "ESIC Management Quota" for admission to Undergraduatecourse, i.e. MBBS in ESIC Medical Colleges for the Academic Session 2014-15.

OATE

PLACE

REGIONAL DIRECTOR ISRO lIe(Duly stamped)

ANNEXURE-III

APPLICATION FORMAT FOR 'WARD OF IP' FOR ADMISSION IN ESICMEDICAL COLLEGE FOR UG COURSES (MBBS) UNDER 'ESIC MANAGEMENTQUOTA' FOR ACADEMIC SESSION 2014-15

1. NAME

2. FATHER'S NAME

3. MOTHER'S NAMESelf Attested

4. DATE OF BIRTHPHOTOGRAPH

5. SEX

6. CATEGORY-GENjSCjST JOBCjPH(Specify any other)

7. CORRESPONDENCEADDRESS

8. PERMANANENTADDRESS

9. Contact No.

10. E-mail address

11. INSURANCE NO. OF IP

12. RELATIONSHIP WITH IP

EDUCATION YROF13. BOARD SUBJECTS

QUALIFICATION PASSING

13.1 SECONDARY SCHOOL(10TH)

13.2 SENIOR SECONDARY(+2)

DETAILS of Roll No. Score Rank -All India14. QUALIFYING EXAM,

i.e. AIPMT - 2014

I

I

ANNEXURE-III cont .....

PREFERENCE OF ESIC 1.MEDICAL COLLEGE FORADMISSION TO UG 2.

15. COURSE, i.e. MBBS, FOR 3.ACADEMIC SESSION2013-14. 4.

Signature of IP Signature of the Candidate

xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx

ANNEXURE- IV

List of Enclosures

(All copies to be self - attested)

1. Copy of - School Certificate for proof of Date of Birth

2. Copy of - Senior Secondary School certificate (+2).

Provisional if final has not been issued

3. Copy of admit card for AIPMT-2014

4. Copy of score card (AIPMT-2014) with Rank Position i.e. All

India Rank

5. Copy of - Ward of IP Certificate from Competent Authority.

6. Copy of SC/ST/OBC/PH Certificate from the 'Appropriate

Authority' as specified by the concerned State/UT

Government

7. Copy of Affidavits at Annexure - V

8. Copy of Affidavits at Annexure - IX & X (if applicable)

Annexure - VAFFIDAVIT (By All Candidates)

(On Non-Judicial Stamped paper of Rs )

IIIIIII

I, Ms./Mr , S/D/o Shri , resident of...................................................hereby declare as under1. That I have taken admission to MBBS course at ESIC Medical College

....................................................for the academic year 2014-15.2. That I have deposited tuition fee amount @ Rs. 24,000/- per annum on

provisional basis.3. That it has been explained to me that the fee structure is under revision and

fees are likely to be increased.4. That I have been informed that the final fee to be deposited would be subject

to the decision of the Fee Fixation Committee / Competent Authority whichdecides the fee structure of Government and Private Engineering/MedicalColleges keeping in view the infrastructure, investment, expenditure, etc.

5. That I have also been informed that there could be substantial difference infee paid provisionally at the time of admission and the fee amount as decidedby the Fee Fixation Committee / Competent Authority.

6. That I hereby declare that I shall abide by the decision of the Fee FixationCommittee / Competent Authority on the amount of fee and undertake todeposit the difference, if any.

7. That I have also been informed that the amount of Rs. 7.5 lacs towards failureto fulfill obligation under Bond is likely to be revised by the CompetentAuthority and I hereby declare and undertake that I will abide by the decisionin respect of revision in amount of Bond.

8. I hereby state that I have given the aforesaid undertaking to pay thedifference in the Fees, if so decided by the Fees Fixation Committee/Competent Authority, and pay revised amount as decided by the CompetentAuthority, towards failure to fulfill obligation under Bond, out of my own freewill.

DEPONENTVERIFICATION

I swear by this Affidavit that the contents of my above Affidavit are true andcorrect to my knowledge and belief and no part of it is false.Verified at on this day of August, 2014

DEPONENT[To be duly Notarized]

ANN E XUr<E - VI-The form of certificate to be produced by Scheduled Castel Scheduled Tribe candidatesapplying forappointment to posts under the Government of India.

'This is to certify that Shri/Shrimati/Kumari*

son/daughter* of ofvillage/town* .

.................................................. in District/Division * of the State/Union Territory*

........................................................... belongs to the caste/tribe* which

is recognized as Scheduled Caste/Scheduled Tribe* under:-

@ the Constitution (Scheduled Castes) Order, 1950@ the Constitution (Scheduled Tribes) Order, 1950@ the Constitution (Scheduled Castes) (Union Territories) Order, 1951@.the Constitution (Scheduled Tribes) (Union Territories) Order, 1951[as amended by the Scheduled Castes and Scheduled Tribes List (Modification) Order, 1956; theBombay Reorganisation Act, 1960; the Punjab Reorganisation Act, 1966; the State of HimachalPradesh Act, 1970; and the North Eastern Areas (Reorganisation) Act, 1971 and the ScheduledCastes and Scheduled Tribes Orders (Amendment) Act, 1976, the State of Mizoram Act, 1986 theState of Arunachal Pradesh Act, 1986 and the Goa, Daman and Diu (Reorganisation) Act, 1987.]@ the Constitution (Jammu and Kashmir) Scheduled Caste Order, 1956@ the Constitution (Andaman and Nicobar Islands) Scheduled Tribes Order, 1959 as amendedby the Scheduled Castes and Scheduled Tribes Order (Amendment) Act, 1976.@ the Constitution (Dadra and Nagar Haveli) Scheduled Castes Order,1962.@ the Constitution (Dadra and Nagar Haveli) Scheduled Tribes Order,1962.@ the Constitution (Pondicherry) Scheduled Castes Order, 1964.@ the Constitution (Uttar Pradesh) Scheduled Tribes Order, 1967.@ the Constitution (Goa, Daman and Diu) Scheduled Castes Order, 1968.@ the Constitution (Goa, Daman and Diu) Scheduled Tribes Order, 1968.@ theConstitution (Nagaland) Scheduled Tribes Order, 1970.@ the Constitution (Sikkim) Scheduled Castes Order, 1978 @ the Constitution (Sikkim)Scheduled Tribes Order, 1978.@ the Constitution (Jammu & Kashmir) Scheduled Tribes Order, 1989@ the Constitution (SC)Order (Amendment) Act, 1990.@ the Constitution (ST) Order (Amendment) Act, 1991.@ the Constitution (ST) Order (Second Amendment) Act, 1991.@ the Scheduled Castes and Scheduled Tribes Orders (Amendment) Act, 2002.@ the Constitution (Scheduled Castes) Order (Amendment)Act, 2002.@ the Constitution (Scheduled Castes and Scheduled Tribes) Orders (Amendment)Act, 2002.@ the Constitution (Scheduled Castes) Orders (Second Amendment)Act, 2002.@

%2. Applicable in the case of Scheduled Castes/Scheduled Tribes persons who have migrated

from one State/Union Territory Administration to another.

This certificate is issued on the basis ofthe Scheduled Castes/ Sch ed u Ie d Tri bes

certificate* issued to Shri/ Shrirmati* father/mother of Shri/

Shrimati/Kumari* .............................................. of village/ town*

.................................... in District/Division* of the State/Union

Territory* who belongs to the caste/

tribe* which is recognised as a Scheduled Caste/Scheduled Tribe* in the State/Union

Territory issued by the dated .

% 3. Shri/Shrimati/Kumari* . and/or* his/her" family

ordinarily reside(s) in village/. town* of

District/Division* of the State/Union Territory* of.. .

Signature .

**Designation (With Seal of Office)

Place: State/Union Territory * .

Date: .*Please delete the words which are not applicable.@ Please quote specific Presidential order.% Delete the paragraph which is not applicable.NOTE: The term "Ordinarily reside(s)" used here will have the same meaning as in Section 20

of t he Representation ofthe People Act, 1950.

**List of authorities empowered to issue Scheduled Caste/Scheduled Tribe/OBC Certificates.(i) District Magistrate/Additional District Magistrate/ Collector/Deputy

Commissioner/Additional Deputy Commissioner/Deputy Collector/1st Class Stipendiary

Magistrate/' ..Sub-Divisional Magistrate/Taluka Magistrate/ Executive Magistrate/Extra

Assistant Commissioner. (...not below the rank of 1st Class Stipendiary Magistrate).

(ii) Chief Presidency Magistrate/Additional Chief Presidency Magistrate/Presidency

Magistrate.

(iii) Revenue Officers not below the rank ofTehsildar.

(iv) Sub Divisional Officer of the area where the candidate and/or his family normally resides.

The form of certificate to be produced bOthappointment to posts under the G Y er Backward Classes candidates applying for

overnment of India.

This is to certify that Shri/Shrimati/Kumari*of Shri son/daughter*

...................................... of viilage/town*Division* . .. in District/

..................................... of the State/Union Territory *th belongs toe community which is recognised as a backward class under;-

@Government of India, Ministry of Welfare Resol .September, 1993 published in the Gazette of lndi E unon .No. 12011/68/93-8CC(C)dated 10ththe 13th September, 1993. la xtraordlnary Part I, Section I, No. 186 dated

@Govemment of India, Ministry of Welfare Re I .published in the Gazette of India Ext di so ution No. 12011/9/94-8(( dated 19-10-94

raor marv Part I Section I N 163 d r

@Govemment of India, Ministry of Welfare R: ,0. ated 20-10-1994.published in the Gazette of Ind ia Ext ra 0 rdi esolution No.. 12011/7/95-8(( dated 24-5-95,@Government f . " inarv Part I, Section I, No. 88 dated 25-5-19951996 publishe: /;d~~z~~~~st~ ~~~:If~r~ Res~l.utionNo. 12011/96/94-8(( dated 9th March,March,1996. x raor marv Part I, Section I, No. 60 dated 11th

@Government of India Mi . t f W If' rus ry 0 e are Resolution No. 12011/44/96-8(( dated 6th

1D1echember,1996 published in the Gazette of India Extraordinary Part I Section I No 210 datedt December,1996. r ,.

@Government of I~dia, ~inistry of Welfare Resolution No. 12011/13/97-8(( dated 3rdDecember, 1997 published In the Gazette of India Extraordinary Part-I, Section-I, No. 239 datedthe 17th December, 1997.

@Govemment of India, Ministry of Welfare Resolution No. 12011/99/94-8(( dated the 11thDecember, 1997 published in the Gazette of India Extraordinary Part I, Section I, No. 236 datedthe 12th December,1997.@Government of India, Ministry of Social Justice and Empowerment Resolution No.12011/68/98-B(( dated the 27th October, 1999 published in the Gazette of India ExtraordinaryPart I, Section I, No.241 dated theLilh October, 1999.@Government of India, Ministry of Social Justice and Empowerment Resolution No.12011/88/98-8(( dated the 6th December, 1999 published in the Gazette of India ExtraordinaryPart I, Section I, No.270 dated the dh December, 1999.@Government of India, Ministry of Social Justice and Empowerment Resolution No.12011/36/99-B(( dated the 4th April, 2000 published in the Gazette of IndiaExtraordinary Part I, Section I, No.. 71 dated the 4th April, 2000.@Government of India, Ministry of Social Justice and Empowerment Resolution No. 12011/44/99-B(( dated the 21st September, 2000 published in the Gazette of India Extraordinary Part I, Section I,No. 210 dated the 21st September, 2000.@Government of India, Ministry of Social Justice and Empowerment Resolution No.12015/9/2000-B(( dated the 6th September, 2001 published in the Gazette of IndiaExtraordinary Part I,Section I, No. 246 dated the 6th September, 2001.@Government of India. Ministry of Social Justice and Empowerment Resolution No.12011/1/2001-B(( dated 19th June, 2003 published in the Gazette of India Extraordinary Part I,Section I, No. 151 dated 20th June, 2003.@Government of India, Ministry of Social Justice and Empowerment Resolution No.12011/4/2002-B(( dated 13th January, 2004 published in the Gazette of India Extraordinary, PartI Section I No.9 dated 13th January, 2004.@Govern~ent of India, Ministry of Social Justice and Empowerment Resolution No.12011/9/2004-8(( dated 16th January, 2006 published in the Gazette of India Extraordinary, PartI,Section I, No. 10 dated 16th January, 2006.

@Government of India, Ministry of Social Justice and Empowerment Resolution No.12011/14/2004-BCC dated 12th March, 2007 published in the Gazette of India Extraordinary, PartI,Section I, No. 67 dated 12th March, 2007.@Government of India, Ministry of Social Justice and Empowerment Resolution No.12015/2/2007-BCC dated is" August, 2010 published in the Gazette of India Extraordinary,Part I, Section I, No. 232 dated 18th August, 2010.@G'overnment of India, Ministry of Social Justice and Empowerment Resolution No.12015/2/2007-BCC dated 11thOctober, 2010 published in the Gazette of India Extraordinary,Part I, Section I, No. 274 dated 12th October, 2010.@Government of India, Ministry of Social Justice and Empowerment Resolution No.12015/15/2008-BCC dated is" June, 2011 published in the Gazette of India Extraordinary,Part I, Section I, No. 123 dated 16th June, 2011.@Government of India, Ministry of Social Justice and Empowerment Resolution No.12015/13/2010-BC-1I dated s" December, 2011 published in the Gazette of India Extraordinary,Part I, Section I, No. 257 dated 08th December, 2011.

Shri/Shrimati/Kumari * and/ or" his/her" fam iIy ord inarily

reside(s) in village/town* of District/Division* of the .

State/Union Territory * of This is also to certify that he/she* does

not belong to the persons/ sections* (Creamy Layer) mentioned in column 3 of the

Scheduleto the Government of India, Department of Personnel & Training O.M. No. 36012/22/93-

Estt.(SCT)dated 8-9-1993, O.M. No. 36033/3/2004-Estt. (res.) dated 9th March, 2004, O.M.

36033/3/2004-Estt. (Res)dated 14-10-2008 and OM No. 36033/1/2013-Estt.(Res.) dated 27.5.2013.

Signature .

* *Designation (with seal of office)

Place .Date .

Note 1: The format of undertaking to be furnished along with the OAFby Other Backward Classcandidates applying for appointment to post under the Government of India, is available as

Annexure VI.Note 2: Creamy layer clause in respect of OBCcandidates must be as per OM No. 36033/1/2013-

Estt.(Res.)dated 27.5.2013 . . .Note: The term "ordinarily reside( s)" used here will have the same me arung as In Section 20

oft heRepresentation of the People Act, 1950.*Please delete the words which are not applicable.@Strike out whichever is not applicable. . .**L' t f authorities empowered to issue Scheduled Caste/Scheduled Tribe/OBC Certificates.. IS 0District Magistrate/Additional District Magistrate/ collecto:/DeP.ut

y

(cl)mmissioner/Additional Deputy Commissioner/Deputy Collector/1st Class .StIPen/dlary

o . t t / Executive Magistrate ExtraMa istrate/ ...Sub-Divisional Magistrate/Taluka MagiS ra e. .

~ .' ( not below the rank of 1st ClassStipendiary Magistrate).ASSistantCommissioner. ... . id(ii) Chief Presidency Magistrate/Additional Chief Presidency Maglstrate/Presl ency

Magistrate.. b I the rank ofTehsildar. (iv)SubDivisionalOfficer of the areawhere(iii) Revenue Officers not e ow .the candidate and/or his family normally reSides.

FORMAT OF UNDERTAKING TO BE FURNISHED BY OBC CANDIDATES.

UNDERTAKING

"1, son/daughter of Shri Resident

of village/town/ city district... state hereby declare

that I belong to the community which is recognized as a backward

class by the Government of India for the purpose of reservation in services as per

orders contained in Department of Personnel and Training Office Memorandum No.

36012/22/93-Estt.(SCTLdated 8.9.1993. It is also declared that I do not belong to

persons/sections (Creamy layer) mentioned in Column 3 of the Schedule to the above

referred Office Memorandum, dated 8.9.1993, a.M. No. 36033/3/2004-Estt.(ResL

dated 9.3.2004 and 8.9.1993 a.M. No. 36033/3/2004-Estt.(ResL dated 14.10.2008 and

a.M. No. 36033/1/2013-Estt.(Res) dated 27/5/2013.

Signature

Name:

-ANNEx.u«.E- Viti-NAME AND ADDRESS OF THE INSTITUTE/HOSPITAL

DISABILITY CERTIFICATE

Certificate No . Date .

Recent photograph of

the candidate showing

the disability duly

attested by the

Chairperson of the

Medical Board

This is certified that ShrilSmt.lKum .

son/wife/daughter of Shri .. age sex .

identification marks (s) is suffering from permanent disability of

following category:

A. Locomotor or cerebral palsy:

(i) BL-Both legs affected but not arms

(ii) BA-Both arms affected (a) Impaired reach

(b) Weakness of grip(c) Ataxic

(iii) BLA-Both legs and both arms affected

(a) Impaired reach

(b) Weakness of grip(c) Ataxic

(a) Impaired reach

(d) Weakness of grip(e) Ataxic

(vi) BH-Stiffback and hips (cannot sit or stoop)

(iv) OL-One leg affected (right or left)

(v) OA- One arm affected

(vii) MW-Muscular weakness and limited physical endurance.

B. Blindness or Low Vision:

(i) B-Blind

(ii) PB-Partially Blind

C. Hearing Impairment:

(i) D-Deaf

(ii) PD-Partially Deaf

(Delete the category, whichever is not applicable)

2. This condition is progressive/ non-progressive/ likely to improve/ not likely to improve.

Re-assessment of this case is not recommended/ is recommended after a period of

................. years months*.

3. Percentage of disability in his/her case is per cent.

4. Shri/Smt.lKum. meets the following physical requirements

for discharge of his/ her duties :-

(i) F-Can perform work by manipulating with fingers. YeslNo

(ii) PP-Can perform work by pulling and pushing.

(iii) L-Can perform work by lifting.

(iv) KC-Can perform work by kneeling and crouching.

(v) B-Can perform work by bending.

(vi) S-Can perform work by sitting.

(vii) ST-Can perform work by standing.

(viii) W-Can perform work by walking.

(ix) SE-Can perform work by seeing.

(x) H-Can perform work by hearing/speaking.

YeslNo

YeslNo

YeslNo

YeslNo

YeslNo

YeslNo

YeslNo

YeslNo

YeslNo

(xi) RW-Can perform work by reading and writing. YeslNo

(Dr. )

MemberMedical Board

(Dr. )

MemberMedical Board

(Dr. )ChairpersonMedical Board

Countersigned by theMedical SuperintendentlCMOIHead of Hospital (with Seal)

* (Delete whichever is not applicable)

PROFORMA OF HAILING FROM CERTIFICATE

21. Candidates who hail from Arunachal Pradesh,

Manipur, Meghalaya, Mizoram, Nagaland or Sikkim will be

required to submit a certificate to that effect from the same

authorities as are empowered, to issue certificates in regard to

SC/ST/OBC candidates. These certificates

will have to be issued by the competent authorities of the

above States only.

The form of the certificate will be as under :-

"This is to certify that Shri/Shrimati/Kumari* .

son/daughter* of Shri .

Village/Town* in

O· . /0' .. * h '1 f * *istnct rvrsion al s rom

Arunachal Pradesh/Manipur/Meghalaya/Mizoram/Nagaland/Sikkim.

Oate . Signature .

Place . Oesignation .

(Seal of Office)

*Please delete the words which are not applicable.

* *Strike off the names of States not applicable.

ANNEXURE - IX

AFFIDAVIT (By Female Candidate only)

1. That deponent Ms , aged years is the Daughter of

Shri. .

2. Shri......................... is employed with the factory / establishment,

viz covered under ESI Act vide Code No .

3. The father/mother of the deponent is beneficiary under the ESI Act having

Insurance no .

4. The deponent is unmarried.

5. The deponent hereby declares that aforesaid facts are correct on the basis of

the record and if the aforesaid declaration is found to be incorrect and

contrary to the records, the admission sought shall be declared illegal and

liable to be cancelled.

6. The deponent further declares that if the information submitted by the

deponent is found to be incorrect the deponent would be liable to be

prosecuted in accordance with law.

DEPONENT

VERIFICATION:

I swear by this Affidavit that the contents of my above affidavit are true and

correct to my knowledge and belief. No part of it is false and nothing relevant has

been concealed therein.

Verified at on this day of August, 2014.

DEPONENT

IIIIII

[To be duly Notarized]

ANNEXURE - XAFFIDAVIT

(By IP - only in case of female candidate)

1. That deponent is an employee with the factory/establishment,

viz......................... covered under ESI Act vide Code

No The deponent is a beneficiary under ESI Act. having

Insurance No .

2. The deponent has got Daughter (Name: ) is years of

age.

3. The Daughter (Name : ) of the deponent is

unmarried.

4. The deponent hereby declares that aforesaid facts are correct on the basis

of the record and if the aforesaid declaration are found to be incorrect and

contrary to the records, the admission sought shall be declared illegal and

liable to be cancelled.

5. The deponent further declares that if the information submitted with the

deponent is found to be incorrect the deponent would be liable to be

prosecuted and face the consequential action which the ESI Corporation

may deem fit and proper.

DEPONENT

VERIFICATION

I swear by this Affidavit that the contents of my above affidavit are true

and correct to my knowledge and belief. No part of it is false and nothing

relevant has been concealed therein.

Verified at on this day of August 2014

DEPONENT

[To be duly Notarized]