8/3/2019 Scrutiny Form

1/1

ApplicationFor:

1.Name:

3.DateofBirth

7a.Community

/

5b.Nativity:

1.M 2.F

7b.Caste

Code

Year

3.Other

State

1.State

Quota

IfStudiedinTNState

2.AIQ

2.No

14.AreyouundergoinganyPG

Degree/Diploma/6YrsM.Ch

NeuroSur er MDS e uivalent1.Yes

4.SC 5.ST

Attempts

8a.UG

studiedat1.TN 2.Others

4A.SCA2A.BCM1.OC 2.BC 3.MBC/DNC

MarksObtained

RegistrationNumberFirstappearanceoftheFinalMBBSPartII/FinalB.D.S.

PMR/PDRNUMBER 1.TobefilledbythecandidatesaspertheentriesmadeintheApplicationform.

2.Useonlybluecolorballpointpenforticking

andwriting.

ARNo

ForOfficeUseonlySCRUTINYFORM

1.PG 2.MDS Instructionstofillupscrutinyform

ADMISSIONTOPGDEGREE/DIPLOMA/

6YEARSM.ChNEUROSURGERY/MDSCOURSES

20122013SESSION

10.TotalNo.ofcompletedyearsafterCRRIason31.03.2012(Weightagerestrictedtoamaximumof10)

13.TotalMarksinFinalMBBSPartII/FinalB.D.S.andNo.ofAttempts

9.DateofCompletionofCRRITraining

3.Puttickmark()inthecorrectgraycolor

boxes

4.Writeinsidethewhitebox,wherever

writingisrequired.

5a.Nationality

2.Others

2.Others

4.Sex:

1.TN

1.Indian

SF

/

MaximumMarks

//

8b.UGstudied

16g.No.ofcompletedYearsofServiceason31.03.2012

Candidate'sSignature___________________________________________________________________________________________________

1250/DDDetailsof

coursesatthetimeofapplying

15d.Ifyesmentionthe

dateofdicontinuation

16d.If

selectedby

TNPSC,

/

3.CMC

16a.ServiceParticulars

DDDate

Name:Dr.

15a.WhethercompletedPG

Degree/DNB

15b.Whether

completedDiploma1.Yes 2.No

1.DMS 2.DPH

/

2.No17.AreyouapplyingunderSpecialCategory(PH) 1.Yes

2.NonService

4.Others

IfTNGovt.Servicecandidate,Fillintheboxbelow.

2.No

Yearofselection

3.DME

16c.Selectedunder

Rural

Areas

16e.IfworkinginTNStateGovtService

whetherworkingunder

1.Yes

Hilly

Areas

Tiruvarur,Nagai,

RamnadDts

1.StateGovt 2.LocalBodies

16b.IfServiceCandidate

1.TNGovt.Service

15c.WhetherdiscontinuedPG

Degree/DiplomaCourse/

2a&2b.

Address: DDNo.

Isincerelyaffirmthattheinformation

furnishedabovearetrue.

SpaceforPhotograph

withName&Date

(Tobeattestedbygrade

A/BofficersofCentral/

StateGovernments)

1.TNPSC 2.10a(i)

16f.DateofEntryinto

Govt.Service

TNPSCReg.No

1 2

/

DateofCompletion1.YES 2.NO

No.ofYears

CommunityoftheCandidate

an ame

&Branch

Pincode:

Mobile: