Appendix-I

MAHARASHTRA UNIVERSITY OF HEALTH SCIENCES, NASHIK

UNDER-GRADUATE / POST GRADUATE EXAMINATION FORM
MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS MUHS

Examination Form No. :

To,
The Controller of Examinations, College Code :
MUHS, Nashik.

Sir, UG PG
Admitted Acad. Eligibility Sattus Eligibility
Year (specity only one: Granted, Not Department FRESH REPEATER
Granted, Provisionally Granted) Letter Date
(Please Mark)

I request permission to present myself at the ensuing _________________Examination to be held in

(Class & Course)
Winter/Summer half of 20 . I furnish my details as stated below:-
1. English

(Surname) (First Name) (Middle Name)

In Marathi:

2.
3. in Capital Letters:
4. Candid Letters only:

Pincode:
5. State:
6. College Name:
7. Email Address:
8. Adhar No.
9. Mobile (Adhar Linked):
10 Mobile (Whats App):
11 Gender : MALE: FEMALE:
12 Date of Birth :
Date Month Year
13 Date of Admission :
Date Month Year
14 Admitted in Academic Year:
Total Maximum Attempts Permissable as per
15
Centre Council / University Norms
16 Date of Fee Payment by Student to College:
Date Month Year
Left Hand Thumb Impression
17 Current Exam Attempt

Signature of Candidate in running hand,

within the box

NOTE: It is to be ensured that this Photograph and Signature should match with the Photograph and Signature of Hall
Ticket.

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18. Fees Details of Student
Sr. No Headwise Details of fee Amount

19. List of Documents/Items to be attached/verified:

Documents For
Sr. For MUHS
No.
Particulars attached College
Use only
Yes/No Use only
1. Photograph duly attested by the Dean/Principal

2. Photocopy of marks statement of latest examination

Photocopy of Eligibility letter (For First year Students only) OR Transfer letter (If
3.
Applicable)
FOR PG STUDENTS, following document is also to be submitted:

4. Attendance Certificate of Research Methodology workshop

Log book (for Fresh students) (Soft Copy for Medical Faculty & Hard Copy for
5.
other Faculties.
Students passed out from other Universities, UG Degree certificate of respective
6.
University.
NOTE: Incomplete Examination form and without documents will be rejected by the University.

20. Dress Code:

Sr. Particulars Yes/No*
No.
1. Whether Candidate want to wear Cultural/Traditional Dress during the University Examinations.
[(If Yes, it is mandatory to reamin present at Examination Centre before 01 hour of commencement of
University examinations for proper frisking (checking)].
I will be appearing for the following Subjects (for Subject Name and Subject Code, please refer Theory Time-Table
published by the University on the website):-
For Fresh Students Only
Subject Attendance %
Sr. No Subject Name
Codes Theory Practical HOD Name HOD Sign

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 DECLARATION BY THE CANDIDATE

1) I am aware that, I have to fulfill criteria of attendance prescribed by the University up to commencement of

2) I hereby declare that I have not availed of any attempt (including the present one) in excess of the maximum
attempts permissible by Central Council / University for the said examination (wherever applicable).
3) I hereby declare that I have gone through the syllabus prescribed and relevant rules of Ordinance 1/2014
(amended) Heads of Passing which are applicable for the examination for which I am appearing and I accept the
same without any challenge (wherever applicable). Reference Ordinance 01/2014 rule 59, 60 & 62 for head of
passing and Grace Marks) OR as applicable from time to time.
4) I shall be responsible if my application form is rejected for any errors, wrong or incomplete entries made by me in
the examination form.
5) I hereby declare that I shall not claim any concession on religious ground.
6) I am not defying the criteria of the admission order.
7) I am not admitted to the course after the cut-off date declared by the University for grant of terms.

Place:

Date: Signature of Candidate in running hand

2 0

CERTIFIED BY THE HEAD OF INSTITUTION

I certify that,
Shri/Smt/Kum.
the classes and
1. that his/her attendance is not less than as prescribed by the University & respective council norms in lecture teaching and
practical work, however, in case prescribed attendance is not fulfill up to commencement of examination, Hall ticket of the

2. that the candidate has completed the academic terms and appeared in mandatory number of internal assessment tests as per
the university rules (wherever applicable).
3. that he/she is not admitted to the course after the cut-off date for grant of terms.
4. that the candidate has completed house job (For PG Only wherever applicable)
5. that the information furnished by the said candidate is verified from his/her documents and that the candidate
is Eligible to appear for University Examination.

Place:

Date: 2 0 Signature & Seal of the Dean/Principal

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