Rajiv Gandhi Medical College, Kalwa,

Thane – 400 605

[ Affiliated to Maharashtra University of Health Science, Nashik ]
MBBS ADMISSION FORM
Academic Year : 20___ - 20___

Caste / Category [Please tick relevant box]

SC  ST  VJ  NT  [Specify] _____________
SBC  OBC  PH  Sports  Defence  1-2-3 35 mm x 45 mm
Desert / Hilly area  Project af fected  EWS  RECENT CLEAR
COLOUR
Open (UR) Other [Specify] _____________ Photograph
WITH WHITE
BACKGROUND

EMERGENCY
FULL Name of contact person: __________________________
___________________________________________________
Relationship with applicant: ____________________________ NEET- UG Merit List
Mobile: [1] ___________________ [2] ___________________ No.: _____________
Landline (with STD): _________________________________ State Merit List
Applicant’s Blood Group: ______________________________ No.: -----------------------

Aadhar Card Number:

Voter ID :-

( for those who don’t have Voter ID fill Annexure ‘ C ‘ )

Name of the applicant in CAPITALS – ENGLISH – EXACTLY as per 12th Std Mark sheet

Above-mentioned name of the applicant in DEVNAGARI (Hindi / Marathi) SCRIPT

Gender: M  F  TG  Mother tongue: __________ Religion: ________

Domiciled in the State of _________________ Date of Birth : __ __ / __ __ / __ __ __ __
Place of Birth : _________________ District : _____________ State : ___________
Name of Last School / College attended : __________________________________
Postal address of Last School / College attended : ___________________________
___________________________________________ PIN Code : __ __ __ __ __ __
Page 1 of 6
 Date : __ __ / __ __ / 20 __ __

To,
The Dean,
Rajiv Gandhi Medical College,
Kalwa, Thane-400 605

Name of the applicant in CAPITALS – ENGLISH – EXACTLY as per 12th Std Mark sheet

1. I, the above-named applicant, hereby apply for admission to the First MBBS Course at
Rajiv Gandhi Medical College (RGMC), Kalwa, Thane.
2. I have appeared and qualified at the NEET-UG Examination and I am submitting the
documents as mentioned in Annexure-2. I shall immediately pay all the prescribed Tuition fees,
Deposits, Caution Money, and other dues.
3. I am aware that my admission is provisionally valid till it is approved by the appropriate
authority. If my admission is NOT approved by the Maharashtra University of Health Science
or any other appropriate authority, for whatever reason, I will abide by the given decision as
regards my admission. I am aware that in such a case, my admission will be cancelled at any
time without assigning any reason.
4. I have read the Rules and Regulations and have understood the contents therein. I shall abide
by all the Rules and Regulations in force, and any changes made therein from time to time, as
framed by the appropriate authority.
5. I am NOT employed anywhere and I have NOT taken admission to any other course.
6. I categorically and specifically undertake to maintain the minimum attendance in lectures,
tutorials, and Practicals as prescribed by the Maharashtra University of Health Sciences,
Nashik failing which, I am aware that I will NOT be eligible to appear for the examinations.
7. I undertake to obtain prior written permission of the Dean, RGMC in case of my absence
due to personal circumstances.
8. I undertake to behave in the college and hospital premises and in the public in a manner
befitting the prestige of this institution. I will NOT be indulging in any activity that will be
detrimental to the interest of this college and hospital and tarnish its good name. I will not
participate in any strike or demonstration or union activities.
9. I am aware that the institution will NOT be responsible for loss of valuables, mobile phone and
my other personal belongings.
10. I undertake to inform the Head of my department and Dean, RGMC in writing, in case of any
change in the contact phone numbers and postal addresses of myself and that of my
emergency contact persons, Parents and Local Guardian immediately.
11. I will fill the Online Anti Raging Undertaking form at www.antiragging.in and I am aware that
without submitting Anti Ragging Form Admission process will not be complete.
12. I confirm and state that the information furnished by me in this Admission Form and Annexures-
1 to 2 is true. In case it is found to be false, I am aware that I will be liable for legal action and
that my admission may be cancelled.

Signature of the Applicant: _________________________

Signature of Parent / Guardian: _________________________

Page 2 of 6
 Annexure-1
UNDERTAKING FROM PARENT / GUARDIAN
To,
The Dean,
Rajiv Gandhi Medical College, Kalwa, Thane

The applicant, ________________________________________________________________

Name of the applicant in CAPITALS- ENGLISH – EXACTLY as per 12th Std Mark Sheet

Who is my Son / Daughter / Ward, has applied for admission to the First MBBS Course at Rajiv
Gandhi Medical College, with my consent.
1. I undertake to ensure that Son / Daughter / Ward, abides by the Rules and Regulations Framed
by RGMC / University / Government authorities, and attends classes regularly, comletes all
assignments properly and behaves in the college and in public in a manner befitting the
prestige of your college.
2. I also undertake to ensure that my Son / Daughter / Ward, abides by the institutions and will
not be indulging in any activity that will be detrimental to intrest of this college and tarnish its
good name.
3. I hereby confirm that I am well aware that Ragging is a punishable offence under the
Maharashtra Prohibition of Ragging Act, 1999 (No. XXXIII), and its relevant
amendments and the Medical Council of India’s Prevention and Prohibition of Ragging
Regulations, 2009. I am aware that the punishment can range from suspension, expulsion from
the college and fine and imprisonment. I agree to abide by the terms of these laws and rules
and I will not indulge in the act of ragging other students indirectly or directly.
4. I will fill the Online Anti – Raging Undertaking form at www.antiragging.in and I am aware that
without submitting Anti Ragging Form Admission process will not be complete.
5. I also undertake to ensure that my son/ daughter / ward will not participate in any Strike or
demonstation or union activities.

Date : _ _ / _ _ / 20 _ _ Signature of Parent / Guardian: _________________________

APPLICANT’S PERSONAL DATA

Applicant’s Mobile No. ____________________ & WhatsApp No.: _____________________
Applicant’s E-mail ID: ________________________________________________________
Father name: _____________________________ Father Mobile No.: __________________
Father E-mail ID: ____________________________________________________________
Mother name: ____________________________ Mother Mobile No.: __________________
Mother E-mail ID: ___________________________________________________________
Father Occupation: ________________________ Annual Income: __________________
Mother Occupation: _________________________ Annual Income: ___________________
Permanent / Native Place POSTAL Address: ______________________________________
_________________________________________________ PIN Code: __ __ __ __ __ __
[ COMPALSORY FOR OUTSTATION & HOSTEL APPLICANTS ]

Local Guardian Name: ____________________________________________________

Relationship with Applicant:________________________ Mobile No.: __________________
Local Guardian Email ID:__________________________________________________
Local Guardian POSTAL Address: ______________________________________________

_________________________________________________ PIN Code: __ __ __ __ __ __

Page 3 of 6
 Annexure-2
DOCUMENTS
__________________________________________________________________________
Name of the applicant in CAPITALS – ENGLISH – EXACTLY as per 12th Std Mark sheet

__________________________________________________________________________
Above-mentioned name of the applicant in DEVNAGARI (Hindi / Marathi) SCRIPT
1. The applicant should scan and retain COLOUR soft copies of each document BEFORE he/she
submits the ORIGINAL hard copies. Once submitted, the ORIGINAL hard copies of documents will
be returned only AFTER completion of the MBBS course Only.
2. Submit ORIGINAL hard copies + TWO sets of photocopies in SERIAL ORDER as shown below –
FOR ALL APPLICANTS Certificate No. Dated
A  Photocopy of Aadhar Card ……
B  Photocopy of Voter ID (or Annex ‘C’)
1  NEET-UG Admit Card / Hall Ticket
2  NEET-UG Selection Letter
3  NEET-UG Statement of Marks
Nationality Certificate
4 
Issued by _________________________________
Domicile Certificate
5 
Issued by _________________________________
Mark Sheet 12th Standard
6 
Board : ___________________________________
Passing Certificate 12th Standard
7 
Board : ___________________________________
Grade Equivalence Certificate
8 
Board : ___________________________________
Mark Sheet 10th Standard
9 
Board : ___________________________________
Passing Certificate 10th Standard
10 
Board : ___________________________________
Leaving Certificate from LAST School / College.
11  Name of School / College: ____________________
_________________________________________

Migration Certificate
12 
Issued by _________________________________

Physical Fitness Certificate*

13 
( from MBBS Doctor ) ( Annexure – H )

Page 4 of 6
 Annexure-2 [continued]
DOCUMENTS
WHERE APPLICABLE Certificate No. Dated
Caste Certificate
14 
Issued by _______________________________
Caste Validity Certificate
15 
Issued by _______________________________
Non-Creamy Layer Certificate * ( Annexure – G )
16  Valid till :- __ __ / __ __ / 20 __ __ ( 31/03/2024 )
Issued by _______________________________
Eligibilty Certificate for Economically Weaker
17  Section (EWS) * ( Annexure – A )
Issued by _______________________________
Certificate of Disability (PwD) * ( Annexure – D )
18 
Issued by _______________________________
Parent’s Defence Certificate
19 
(Def-1,Def-2 or Def-3)* ( Annexure – C )
Project Affected  Desert  Hilly Area  *
20 
( Annexure – F )
Parent’s Domicile Certificate *
Issued by _______________________________
21 
( For Candidated Selected under Defence Quota
[Def-1,Def-2 or Def-3] and Hilly Area )
22  Sports __________________________________

23  Gap Affidavit on Rs. 100 stamp paper (Notarized)

24  Any other certificate: ________________________

Transfer / Upgraded Candidates:

25  Relieving Letter from Dean of previous medical
college :__________________________________
( Note : * Applicant must submit Certificate’s as in given Annexure / Proforma as per NEET
Information Brochure – 2023 )
Applicant FOR OFFICE USE ONLY
Signature : _____________________ Originals verified by
Name : ________________________ Clerk :
Signature : ________________
Parent’s / Guardian
Name : ___________________
Signature : _____________________ Date : ____________________
Name : ________________________ ___________________________
Vice Dean ( Signature &
Name & Stamp )
Page 5 of 6
 Annexure'C'

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 Health Science

ANNEXURE - H
MEDICAL FITNESS

A candidate must be medically fit to undergo the professional course applied for. The
medical fitness must be certified by a Registered Medical Practitioner in the prescribed
proforma, as given below on a Letterheador on this format with original seal and signature.

CERTIFICATE OF MEDICAL FITNESS

This is to certify that I have conducted clinical examination of Mr./Ms
.................................................................................... who is desirous of admission to Health
Science Courses.
He/she has not given any personal history of any disease incapacitating him/her to
undergo the professional course. Also, on clinical examination it has been found that he/she
is medically fit to undergo the professional course.
Certified that he/she fulfills the following criteria.
(1) Absence of any incapacitating and /or progressive systemic disease/disorder/condition,
(2) Absence of any disability of upper limb/s.
(3) Absence of any major visual/ auditory disability.
(4) Absence of psychosis/neurosis/mental retardation,
(5) Ability to maintain erect posture,
(6) Reasonable manual dexterity.
Though, following deviations have been revealed, in my opinion, these are not
impediments to pursue a career as a Medical / Dental / Ayurved / Homeopathy / Unani /
Occupational Therapy / Physiotherapy / Audiology & Speech, Language Pathology /
Prosthetics & Orthotics / BSc Nursing. (Strike, which is not applicable):
1. ............................................................................................................................................
2. ............................................................................................................................................
3. ............................................................................................................................................

Address of the Registered Medical Signature

Practitioner
Name

Registration No.

Seal of Registered Medical Practitioner

Date :

Information Brochure ( 108 ) NEET UG-2023