National Medical College, Birgunj, Nepal
Affilated to Tribhuvan University, Nepal & reconized by Nepal Medical Council
 

Application for Enrollment
To,
The Board of Directors
National Medical College
Birgunj, Nepal
Photo
Dear Sir,

I hearby apply for membership of your institute, My personal details are filled in below.

PERSONAL DETAILS.
1.
NAME OF APPLICANT:
 SURNAME
(Family name)
 FIRST NAME
2.
MARITAL STATUS:
 Mr Miss Mrs  
3.
SEX:
 MALE FEMALE    
4.
DATE OF BIRTH:
 IN B.S.
yyyy/mm/dd
 IN A.D. dd/mm/yyyy
5.
PLACE OF BIRTH:
        
    VILLAGE TOWN
    CITY COUNTRY
6.
FATHER'S FULL NAME:
      
7.
MOTHER'S FULL NAME:
      
8.
PERMANENT ADDRESS:
        
    LOCALITY STREET NAME & NUMBER
    V.D.C/MUNCIPALITY CITY/TOWN
    WARD NUMBER DISTRICT
    COUNTRY    
    TEL NO. ALTERNATIVE NO.
    FAX NO. E-MAIL
9.
NAME OF LOCAL GAURDIAN:
   PLACE
    TEL NO.    
 
CONTACT ADDRESS IF OTHER THAN PERMANENT ADDRESS:
    V.D.C/MUNCIPALITY CITY/TOWN
    WARD NUMBER DISTRICT
    COUNTRY    
    TEL NO.(OFFICE) TEL NO.(RESIDENCE)
    FAX NO. E-MAIL
10.
CITIZENSHIP:
      
           

ACADEMIC RECORD:

11.

SCHOOL LAST ATTENDED
        
a Examination School Name & Address Year of Passing Subjects Marks Percentage
  SLC
CLASS X
           

QUALIFYING EXAMINATION I Sc., 10+2 OR EQUIVALENT:
b Examination College/University Name & Address Year of Passing Science Subjects Latter Grade
    Marks Percentage
Physics
Chemistry
Biology
English
Total Aggregate %  
 
12.

CONTACT PERSON IN CASE OF EMERGENCY:
  a)In Nepal(if any)        
    Name Relationship
    Full Address :
(city/town/prefecture)
 E-mail
    Tel No.(office) Tel No.(Residence)
    Fax No.    
  B)In Home Country        
    Name Relationship
    Full Address :
(city/town/prefecture)
 E-mail
    Tel No.(office) Tel No.(Residence)
    Fax No.    
 

DECLARATION:
I, the under signed hereby declare that the above information is true and complete and that all certificates submitted with this application are genuine. I understand that any false or incomplete information in support of my application may invalidate my application and result in withdrawl by National Medical college of any offered seat, and that this withdrawal may take place at any time during my enrollment, and registration with Tribhuvan University, and that I promise to bear all the monetary and academmic consequences that may fall upon me there after. I also declare that I have read and fully understood the rules and regulations of this college and Tribhuvan University and promise to that if I am admitted to the MBBS degree course of this college, I will observe them and will act faithfully, creditably and honestly in the exercise of the previlages conffered upon me as a graduate student of this college. I futher undertake to abide by the laws of the kingdom of Nepal during my studies and stay at the college. I authorize National Medical College to obtain nay information relating to my academic recordsat the institutions listed above with a view to acertain them.
Sign
Date
  (Signature of applicant)    

DECLARATION OF PARENTS:

We, the undersigned make our pledge that it is our intention to have our son/daughter________________________________________admitted in the MBBS program of the National Medical College,Birgunj Nepal. That we are willing and are able to provide with all the fundings to support my son/daughter financially which he/she will need during his/her study at this college, that we are ready and willing to deposit a bond to gaurantee that our son/daughter will not become a public charge during his/her stay in the kingdom of Nepal. That we promising to make a full payment of tution fees of the whole course of our son/daughter in case his/her registration with Tribhuvan universityis refused by its concerned authority owing to his/her false certification, wrong declaration or documentation which may result in withdrawal of my son/daughter from the offered seat of the MBBS program at any time during his/her study at the college. That we promise not to hold National Medical College responsible in the event of of such refusal and withdrawal of my son/daughter from the offered seat and will make no complain against it anywhere. If we do it should be regarded as voilation of this pledge and thus be declared null and void. That wehave read and fully understood the rules regulations terms and conditions of the college and have discussed them thread-bare with the authority of the college will before signing this document. That we made this affidavit for the purpose of National Medical College to safeguard its intrest at times of need.
Name Of Parents:  
Father
Mother
Address Tel No.
(Signature of Father)    
(Signature of Mother)  
Date

CERTIFIED XEROX COPIES OF CERTIFICATES TO

BE SUBMITTED ALONG WITH THE APPLICATION FORM
 

RULES AND REGULATIONS
1. The payment towards admission fees as decided by the board of directors shall be collected as per scheme-A or scheme-B offered to the member applicants.
   
2. Enquires and communications shall be entertained only by the office /branch of the institute through which admission was sought for by the applicant.
   
3. The admission fee paid by the members is non-refundable.
   
4. The member is entitled for one seat of the MBBS Program offered by National Medical College, Nepal.
   
5. The member can avail admission for the MBBS program of institute in the academic year requested by the applicant and confirmed by the institute.
   
6. The student for the MBBS program will have to satisfy all the eligibility conditions stipulated by the institute and the Tribhuvan university for admission to the MBBS program.
   
7. Students will be required to deposit Rs. 5000/= caution deposit at the time of admission which is refundable after the completion of the course.
   
8. Expenditure during community field experience placement must be borne by the individual students.
   
9. The students will have too strictly abide by the code of conduct of the institute and shall be subject to diciplinary action for any voilations.
   
10. On admission, a temporary reciept shall be issued to the member immediately and the original certificate of membership shall be issued to the member within 60 days thereof.
   
11. The Board of Directors of the National Medical Collge reserves the exclusive right to accept or reject membership applications at thier discretuion.