Maharashtra University Of Health Sciences, Nashik

APPLICATION FORM FOR TRANSFER OF INTERNSHIP FROM OUT OF STATE TO MUHS

Application for transfer for doing Internship Training Programme of Health Sciences courses, from one approved / recognised Health Sciences College from other State to Health Sciences College affiliated to Maharashtra University of Health Sciences, Nashik.

(Please use capital letters to fill the form)

1) Name of the Applicant : ______________ _____________ _____________________

SURNAME FIRST NAME MIDDLE NAME

2) Address for correspondence : ________________________________________________________________

______________________________________________________________

3) Date of Birth :

(as entered in the register of Date Month Year

the College)

4) Name of Parent /Guardian : __________________ __________________ _________________

SURNAME FIRST NAME MIDDLE NAME

5) Tel. No. :____________________ E-mail Address.: _________________________________________

6) Name and address of approved / recognised

College in which studying with E-mail : _____________________________________________________________

_____________________________________________________________

7) Name of the University to which the relieving college is affiliated : _________________________________________

8) Name and address of approved/ recognised ___________________________________________________________

College to which Transfer is desired

with E-mail ___________________________________________________________

9) Details of Demand Draft : DD No.......................Amount ........... Date......... Name of the Drawee Bank...........................

10) Give the following information :

Sr. No.	Name of Exam.	Date & Year of Passing	Marks obtained out of	No. of attempts	Corrected Marks (for office use)
1)	1^st Year
2)	2^nd Year
3)	3^rd Year
4)	4^th Year

11) Please enclose the following Certificates along with D.D. for Rs. 1000/- drawn in favour of the Registrar, Maharashtra University of Health Sciences, Nashik from Nationalised Bank payable at Nashik with application.

i) Ist /IInd/IIIrd/ Final Year Health Sciences Degree Course Marksheets and Attempt Certificate, (Attested Copies)

ii) No Objection Certificate from Relieving College (Original)

iii) No Objection Certificate from University to which relieving college is affiliated. (Original)

iv) No Objection Certificate from Receiving College (Original)

v) Certificate from the Respective Deans/ Principals stating that the Colleges are approved / recognised by concerned Councils ( Original)

12) Grounds for Transfer (if any) : ___________________________________________________________________

(Please attach supporting documents in support of ground s for transfer)

13) Declaration:

I, hereby declare that the information given above is true to the best of my knowledge and belief.

Place :

Date :

Signature of Applicant

N. B. : Please write Name and address on back side of Demand Draft.

ANNEXURE

PRESCRIBED FORM FOR NO OBJECTION CERTIFICATE OF RECEIVING COLLEGE AFFILIATED TO MUHS

NAME OF THE RECEIVING COLLEGE : _______________________________________________________

Subject: Issue of No Objection Certificate to .......................................................

Reference: His/Her application dated ....................................................................

With reference to the above, I have to state that this College has No Objection to allow Shri/Kumari.………………….......…………………….................................for doing Internship Training Programme in this College against the 3% (2% for Regular Batch & 1% for Odd Batch) limit of the intake capacity. The intake capacity of the College is............

Signature : ____________________

Name : ____________________

Date :- ____________ DEAN/PRINCIPAL

Place:- ____________ Seal of the College

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(For Office Use)

RECEIPT

Received application bearing No...................dated..................from Shri/ Kum. ..............................................……….

for transfer for doing Internship Training Programme with the copies of the following documents and fee :

i) Ist/IInd /Final Year Examination Mark sheet & Attempt Certificate, ( True Copy)

ii) No Objection Certificate from Relieving Parent College,

iii) No Objection Certificate from the University to which relieving college is affiliated.

iv) No Objection Certificate from Receiving/ Admitting College,

v) Certificate from the Dean/Principal stating that the College is approved / recognized by Medical Council of India .

vi) D.D. for Rs.1000/- towards transfer fee drawn in favour of the Registrar, Maharashtra University of Health Sciences, Nashik from Nationalised Bank payable at Nashik.

ix) Medical Certificates (If applied on Medical Ground)

Signature of Receiving Officer

Date :- __________