APPLICATION FOR ALLOCATION OF MBBS SEAT FROM SPOUSE/CHILD OF THE CIVILIAN VICTIMS OF TERRORISM. 1. Name of the Applicant : (In Block Letters) 2. Father's /Husband's/Wife's Name: 3. Date of Birth: 4. Residential Address: 5. Educational Qualifications: Sl. No Exam. Passed Board/University Medium Year Total %age of marks obtained Class/Division 6. Relationship with the Terrorist Victim: 7. Details with regard to the Terrorist Incident(s): 8. Name of the Victim: (Separately for father & mother wherever applicable): 9. Age of Victim: Affix attested recent passport size photograph 10. Date & place of the terrorist incident: 11. Terrorist Organization(s) involved in: the incident (to be fill in by the State Police). 12. Fact sheet of the terrorist incident: (to be given by the State Police/State Govt.) 13. Nature of injury & disability caused to: the victim (to be confirmed by the State Police/State Govt.). 14. Action taken by the Police/State including: Registration of FIR, etc. (to be filled in by the State Police/State Govt.) 15. Ex-gratia relief provided by the State Govt./: any other Organization. 16. Family details of the Terrorist Victim: 17. Remarks Declaration I hereby declare that all statements made in th application are true, complete and correct to the best of my knowledge and belief. I understand that in the event of any information being found fake or incorrect, my candidature for the MBBS Course is liable to be cancelled/rejected at any stage without notice to me. SIGNATURE OF CANDIDATE Place: Date: CERTIFICATE This is certified that I have personally verified the details of the application based on the record placed before me and found them correct, Having satisfied therefore, I recommend the candidature of the applicant for consideration for allocation of MBBS seat from the Central Pool for spouse/child of the civilian victim terrorism. Date: ( ) Secretary (Home Department Govt. of __________________ Seal
