KATHMANDU MEDICAL COLLEGE
(AFFILIATED TO KATHMANDU UNIVERSITY & RECOGNISED BY NEPAL MEDICAL COUNCIL
APPLICATION FOR THE MBBS PROGRAMME 201 - 201
(To be filled by the applicant in BLOCK LETTERS in English)
Form No.
FOR OFFICE USE ONLY
Form No. ...................
Date of received ........................................................................ Applicant's recent
Student category- Res. Nepali SAARC Extra SAARC PP size photograph
Fee paying Scholarship
to be pasted
Document checklist- I.Sc. or 10+2 SLC Birth Certificate
Migration Certificate Citizenship Certificate/Passport/Identity Fee
PCBE mark % ....................................................................
Aggregate marks % .............................................................
Remarks of the Board- Eligible Not Eligible
Physically- Fit Unfit
Final Remarks ..................................................................................
Date ...................... Principal's Signature
Seal .........................
1. Name .........................................................................................................................................................................................................................
Surname (or family name) first name other name(s)
2. Sex Male Female
3. Date of birth (in B.S.) ....................../...................../......................... Age : ................................/......................../.....................
Date of birth (in A.D.) ...................../...................../.......................... year month day
date month year
4. Place of birth ............................................................................................................................................................................................................
5. Father's full name .....................................................................................................................................................................................................
6. Mother's full name ...................................................................................................................................................................................................
7. Permanent address : Locality ................................................................................................................. Ward ..................................................
VDC/Municipality ........................................ District ................................... Tel. No. (Res.) ................................. E-mail .................................
8. Name of local guardian (For parents residing outside Kathmandu) ................................................................................................................
9. Contact address in Kathmandu .............................................................................................................................................................................
10. Address for correspondence .................................................................................................................................................................................
(if other than permanent address)
11. Phone (Res.) ....................................................... Off. ..................................Fax........................... Mobile ............................................................
12. Nationality ................................................................................................................................................................................................................
13. If Nepali, whether residing abroad Yes No Which Country .....................................................
EDUCATION
14. (a) List School and College/university attended
Examination School/Address Year of Passing Percentage (Aggregate)
SLC Class X
(b) Qualifying examination I.Sc. 10+2 or equivalent
Examination Year of Passing College/University address Science Marks Percentage
Subjects
Physics .................................................................
Chemistry .............................................................
Biology ..................................................................
English ....................................................................
PCBE aggregate % .................................................
Total aggregate % .................................................
(c) KUMET Result KUMET Seat No. MBBS entrance
Other
Examination Year Subjects Marks/Score
15. Persons to be contacted and notified in case of emergency:
(a) In Nepal ...............................................................................................................................................................................................................
Name Relationship
Full Address ...................................................................................................................................... Phone ..........................................................
(b) In the Home Country ........................................................................................................................................................................................
Name Relationship
Telephone Number: Office Residence Mobile
E-mail ......................................................................
16. Declaration by the Applicant
I hereby certify that the information given in this application form is complete and accurate to the best of my knowledge
and belief. I further undertake to abide by the laws of Nepal and rules and regulations of Kathmandu University and
Kathmandu Medical College during the period of my studies and renounce my right under the laws of any other country
including my home country in matters pertaining to my admission into the MBBS programme of Kathmandu Medical
College, Nepal.
Date: Signature of the Applicant
17. Declaration of Parents
We the parents whose address is .........................................................................................................................
hereby make our solemn promise, that it is our intention to have our son/daughter,
Mr./Ms. ..................................................................................... admitted in the MBBS
programme of Kathmandu Medical College affiliated to Kathmandu University.
That we are willing and able to maintain, and support the prospective student.
That we are ready and willing to deposit a bond, if necessary, to guarantee that such prospective student will not become
a public nuisance during his/her stay in Nepal.
That this affidavit is made by us for the purpose of assuring the Kathmandu Medical College
that Mr./Ms .................................................................................................................................. (name of student)
will not find it necessary to appeal to the KMC for scholarship or other material aid.
We further undertake to abide by the laws of Nepal and Kathmandu Unversity in matters pertaining to the admission of
our ward and renounce our rights under the laws of any other country including our home country.
Name of Parents: Father .................................................................. Mother ........................................................
Address .....................................................................................................................................................................
(Full postal address with Telephone Number)
E-mail: .................................................................................
Signature of Father ......................................................
Signature of Mother ....................................................
Date ..........................................................................
CERTIFIED PHOTOCOPIES OF CERTIFICATES TO BE SUBMITTED ALONG WITH APPLICATION FORM
1. Transfer certificate from the Institution last studied in.
2. Migration Certificate (For international student original).
3. Bonafide and conduct certificates.
4. Certificate of proof of date of birth.
5. Class 10 or Equivalent examination Pass Certificate.
6. Mark-sheet of 10+2 or Equivalent Certificate
7. Citizenship Certificate / Passport / Identity Paper.
N.B.: Indian students should submit no objection certificates from the Medical Council of India.
