APPLICATION FORM

Postal Order No.74F 347909

Date : 3/12/2010
Name of issuing post office : Govindpura Bhopal
Amount : 20 Rs.
APPLICATION FORM
1. Name : RICHA YADAV
2. fFather’s Name : M.C. YADAV
3. Ppostal address for : B-47, NEW MINAL RESIDENCY
Ccorrespondence J.K. ROAD, BHOPAL (M.P.)
4. Ppermanent address : JR. HIG-B/8, SPM NAGAR,
5.
VIDISHA (M.P.)
6. Ccontact Telephone No. & : 0755-4232487, 9589363429
email : richayadav08@gmail.com
7. dDate of Birth : 12-JUNE-1983
8. nNationality : INDIAN
9. Wwhether S/C,, S/T, OBC : NO
10. Yyear of pasingpassing MBBS/BDS : 2007
& university : JIWAJI UNIVERSITY, GWALIOR (M.P.)
11. nNo. of attempts in passing final: FIRST
MBBS/BDS
12. ddate of Completion of : 31-DEC. 2008
internship and Name of : MAHARANA PRATAP COLLEGE OF
institution DENTISTRY & RESEARCH CENTRE,
GWALIOR (M.P.)
13. pPercentage (Aggregate) : 71%
in final :
MBBS/BDS
Examination
14. pPermanent DMC/MCI/State : A-2281, INDORE (M.P.)
M.C. or DCI/State D.C.
Registration No. & Place
15. jJunior REsisdencyResidency (House Job) NO
16.

17. UNDERTAKING
I solemnly declare that the above statements made by me are correct to the best of
my knowledge and belief. In the event of any information found incorrect my candidature
will be liable for rejection summarily. I have no done one year Junior Residency, in any
hospital.

18. check list (Please tick in the box given below as proof of enciosures).
Final Permanent Internship attempt Postal order All
MBBS/BDS Registraiton completion certificate certificates
Marks sheet Certificate certificate attested by a
(Part-I & II) GAzetted
officer

Signature of Applicant

I solemnly declare that the above statements made by me are correct to the best of
my knowledge and belief. In the event of any information found incorrect my candidature
will be liable for rejection summarily. I have no done one year Junior Resisdency, in any
hospital.