1. |
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Name of the applicant
(in BLOCK letters) |
: |
2. |
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Complete Address with PIN code,Telephone nos., Fax and e-mail (in BLOCK letters) |
: |
3. |
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Status of applicant
(Whether State Government/ Union Territory/University/ Trust/Society) |
: |
4. |
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Details of the Society/Trust (To be filled in if the applicant is a Society or Trust) |
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a. |
Name of the Society/Trust
(Attach a copy of the Registration
certificate) |
: |
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b. |
Registration No./Date |
: |
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c. |
Members of the Society/Trust |
: |
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d. |
Major activities of the Society/Trust
(Attach a certified copy of the memorandum of association and bye laws) |
: |
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e. |
Does the Society/Trust run other medical colleges or other educational institutions? If so, please give details
(Strike out what is inapplicable) |
Yes/No |
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f. |
Whether one of the objectives of the Society/Trust is to impart education in Ayurveda, Siddha or Unani.
(Strike out what is inapplicable) |
Yes/No |
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g. |
Whether copies of Balance Sheet and Statements of Account for the last three years duly certified by a Chartered Accountant have been furnished.
(Strike out what is inapplicable) |
Yes/No |
5. |
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Name of the college with full address, PIN code, Telephone Nos., Fax Nos. and e-mail address . |
: |
6. |
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Course/s being conducted in the college
(Please give details of each of the PG courses where applicable) |
UG -
PG -
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7. |
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No. of seats
(Please give details for each of the PG courses where applicable) |
:UG -
PG -
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8. |
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Name and address of the affiliating University |
: |
9. |
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Whether Consent of Affiliation from the affiliating University is continuing
(Copies to be attached) |
Yes/No If yes,
No. of seats ____________
Period of consent from ______ to ______
(Please give the position separately for UG and PG courses) |
10. |
|
Whether the permission of the State Government is continuing
(Copies to be attached) |
Yes/No If yes,
No. of seats ____________
Period of consent from ______ to ______
(Please give the position separately for UG and PG courses) |
11. |
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Name of the Principal/Dean of the college with qualifications and experience. |
: |
12. |
a. |
When did the college first start admitting students?
|
UG -
PG -
(Please indicate the years for the UG and PG courses separately) |
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b. |
Whether admissions have been made continuously every year
(Strike out what is inapplicable) |
Yes/No |
13. |
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Whether CCIM' permission was obtained for starting the college/higher course
(Please enclose a copy) |
Yes/No
If yes, No. and date of the CCIM order |
14. |
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Mode of admission |
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15. |
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Is there any reservation or preferential allocation of seats |
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16. |
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Details of land and buildings |
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a. |
Survey No.
Village/Town
(If there is more than one plot please give details accordingly) |
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b. |
Plot size (in hectares/sq. mts)
(If there is more than one plot please give details accordingly) |
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c. |
Floor area (in sq. mts)
College
Hospital
Total area |
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17. |
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Connectivity
(Strike out what is inapplicable) |
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a. |
Road access to the college |
Yes /No |
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b. |
Availability of public transport |
Yes/No |
18. |
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Utilities
(Strike out what is inapplicable) |
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a. |
Electric supply |
Yes/ No |
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Connected load |
--------- kVA |
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DG set |
Yes/ No |
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b. |
Water supply
(Strike out what is inapplicable) |
Yes/No |
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Municipal supply |
Yes/No |
|
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Own sources |
Yes/No |
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c. |
Sewerage facilities
(Strike out what is inapplicable) |
Yes/No |
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d. |
Communications facilities
(Strike out what is inapplicable) |
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Telephone |
Yes/No |
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Internet |
Yes/No |
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