I solemenly declare that I      S/o,D/o    Residence of      MBBS/ P.G student department of M.D/M.S    ()  SRMS IMS,Bareilly,am not suffering from any Chronics/Psychitaric illness/Seizures.

• I am suffering from _________________________________________ for which i am under treatment of Dr.____________________________________ and the photocopies of the prescription is enclosed.
• I have been/not been immunized with Hepatitis B or Chickenpox vaccine
• I have been/not been immunized with COVID-19 vaccine
  
  1. Dose-1 Date:______________________
  2. Dose-2 Date::______________________
  3. Dose-3 Date::______________________

Enclosed All Verification Certificates

मैं घोषणा करता / करती हूँ कि:-

1. मैं रैगिंग जैसे घृणिका कार्य में कभी भी सम्मिलित नहीं होऊँगा / होऊँगी ।
2. मैं कैपस के अन्दर मर्यादा का पाल करते हुए अच्छे व्यवहार एवं आचरण का प्रदर्शन करूँगा / करूँगी ।
3. मैं किसी भी छात्र/छात्राओं के साथ ऐसा व्यवहार नहीं करुँगा / करुँगी जिससे कि मानसिक अथवा शारीरिक प्रताड़ना मिले ।
4. मैं किसी भी छात्र/छात्राओं के साथ ऐसा व्यवहार नहीं करुँगा / करुँगी जिससे कि उन्हे लज्जा एवं अपमान महसूस हो ।
5. मैं कैम्पस के अन्दर अथवा बाहर अनुशासित रहकर जूनियर छात्र/छात्राओं को भी अनुशासित रहने की प्रेरणा देता रहूँगा / रहूँगी ।

I,     S/o,D/o Mr./Mrs./Ms.  ,  having been admitted to Shri Ram Murti Smarak, Institute of Medical Sciences, have received a copy of the UGC Regulations on Curbing the Menace of Ragging in Higher Educational Institutions, 2009, (hereinafter called the "Regulations") carefully read and fully understood the provisions contained in the said Regulations.

1. I have, in particular, perused clause 3 of the Regulations and am aware as to what constitutes ragging.
2. I have also, in particular, perused clause 7 and clause 9.1 of the Regulations and am fully aware of the penal and administrative action that is liable to be taken against me in case I am found guilty of or abetting ragging, actively or passively, or being part of a conspiracy to promote ragging.
3. I hereby solemnly aver and undertake that
   a) I will not indulge in any behaviour or act that may be constituted as ragging under clause 3 of the Regulations.
   b) I will not participate in or abet or propagate through any act of commission or omission that may be constituted as ragging under clause 3 of the Regulations.
4. I hereby affirm that, if found guilty of ragging, I am liable for punishment according to clause 9.1 of the Regulations, without prejudice to any other criminal action that may be taken against me under any penal law or any law for the time being in force.
5. I hereby declare that I have not been expelled or debarred from admission in any institution in the country on account of being found guilty of, abetting or being part of a conspiracy to promote, ragging; and further affirm that, in case the declaration is found to be untrue, I am aware that my admission is liable to be cancelled.

Declared this_____________day of____________________month of________________Year

I, Mr./Mrs./Ms.   (full name of parent/guardian) father/mother/guardian of ,  (full name of student with admission /registration/enrolment number, having been admitted to Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly , have received a copy of the UGC Regulations on Curbing the Menace of Ragging in Higher Educational Institutions, 2009, (hereinafter called the "Regulations"), carefully read and fully understood the provisions contained in the said Regulations.

1. I have, in particular, perused clause 3 of the Regulations and am aware as to what constitutes ragging.
2. I have also, in particular, perused clause 7 and clause 9.1 of the Regulations and am fully aware of the penal and administrative action that is liable to be taken against my ward in case he/she is found guilty of or abetting raging, actively or passively, or being part of a conspiracy to promote ragging.
3. I hereby solemnly aver and undertake that
   a) My ward will not indulge in any behaviour or act that may be constituted as ragging under clause 3 of the Regulations.
   b) My ward will not participate in or abet or propagate through any act of commission or omission that may be constituted as ragging under clause 3 of the Regulations.
4. I hereby affirm that, if found guilty of ragging, my ward is liable for punishment according to clause 9.1 of the Regulations, without prejudice to any other criminal action that may be taken against my ward under any penal law or any law for the time being in force.
5. I hereby declare that my ward has not been expelled or debarred from admission in any institution in the country on account of being found guilty of, abetting or being part of a conspiracy to promote, ragging; and further affirm that, in case the declaration is found to be untrue, the admission of my ward is liable to be cancelled.

Declared this___________________day of________________month of______________Year

Verified that the contents of this affidavit are true to the best of my knowledge and no part of the affidavit is false and nothing has been concealed or misstated therein.

Verified at___________________________ (Place) on this the__________________________(day) of______________(month) ,______________(year)

Signature of the deponent:__________________________________________________

I, Mr./Mrs./Ms.    S/D/O  ,    R/o    Phone No:  Neet RollNO:  All India Rank:   Neet Marks: reported for admission in your college(Shri Ram murti Smarak Institute of Medical Sciences, Bareilly) for     course session:2024-25
Do hereby undertake on this the ____________________________(Day), of ______________________ (Month)_______________________ (Year), the following:-

1. I hereby declare ,that entries made by me are complete and true to the best of my knowledge and based on records.
2. I hereby declare that after passing 12^th/MBBS examination in this session___________________ to __________________ I have not taken admission in any institute /College/University.
3. I hereby declare that, I have preparation for the competition during the gap from __________/_________/_______ to__________/_________/_______.
4. I hereby declare that, in the above period against me not any case is registered in any court and nor complaint.
5. I hereby declare that, in the above period, my character is good.

I,    adult, son/wife/daughter of  .Resident of  do hereby declare and give consent out of my free will, without any influence or coercion that in case of any sort of dispute with Shri Ram Murti Smarak Institute of Medical Sciences, Nainital Road, P.S. Bhojipura, Bareilly and It’s Hospital in respect of all sort of payments of fees and chargers and all sort of services, tendered and rendered and to be tendered and rendered by and in Shri Ram Murti Smarak Institute of Medical Sciences, Nainital Road, P.S. Bhojipura, Bareilly and it’s Hospital to me namely  . son/daughter/wife of  . resident of ., all sort of legal cases, applications complaints shall be filed, lodged and instituted in COURTS, TRIBUNAL, CONSUMER DISPUTE REDRESSAL COMMISSION ONLY SITUATED, WORKING AND RUNNING ONLY AT DISTRICT BAREILLY (U.P.) and only the COURTS, TRIBUNALS, CONSUMER DISPUTE REDRESSAL COMMISSION SITUATED, WORKING AND RUNNING ONLY AT DISTRICT BAREILLY (U.P.) shall have the exclusive, absolute and sole jurisdiction to entertain, try and dispose of aforesaid all sort of dispute in respect of all sort of payments of fees and charges and all sort of services, tendered and rendered and to be tendered and rendered by the Shri Ram Murti Smarak Institute of Medical Sciences, Nainital Road, P.S. Bhojipura, Bareilly and it’s Hospital to the above named student. In the presence of Witnesses, I do hereby execute, declare and given consent in respect of mentioned hereinabove out of my free will, without any influence or coercion.
Dated : ……../……/………
Signature:…………………………
Name: .
Thumb Impression

मैं (नाम)    किसी भी प्रकार के विवाद के निर्णय, निवारण और समाधान के लिए, केवल जिला बरेली (उ0प्र0) के न्यायालयों, न्यायाधिकरण, उपभोक्ता विवाद निवारण आयोग के क्षेत्राधिकार के निर्धारण के लिए सहमति एवं घोषणा करता हूॅं ।
मैं,   वयस्क, पुत्र/पुत्री/पत्नी    निवासी    एतद्दवारा अपनी स्वतंत्र इच्छा से, बिना किसी जोर-दबाव के घोषणा करता/करती और सहमति देता/देती हूॅं कि श्री राम मूर्ति स्मारक इंस्टीट्यूट आॅफ मेड़िकल साइंसेज, नैनीताल रोड, भोजीपुरा, बरेली और इसके अस्पताल से संबंधित शुल्को के भुगतानो, व्ययों व सभी प्रकार कीे सेवायें, प्रदान की गयी निविदा व प्रदान की जाने वाली निविदा के लिए मैं    पुत्र/पुत्री/पत्नी   निवासी    यदि कोई विवाद होता है तो सभी प्रकार के कानूनी मामलो/आवेदनांे/शिकायतो को केवल जिला बरेली (उ0प्र0). में स्थापित अदालतो, ट्रिब्यूलन, उपभोक्ता विवाद निवारण में ही दर्ज करूंगा। जिला बरेली (उ0प्र0) में स्थित अदालतो, ट्रिब्यूलन, उपभोक्ता विवाद निवारण आयोग में शिकायत और पैरवी करना केवल पूर्ण व एकमात्र अधिकार क्षेत्र होगा। श्री राम मूर्ति स्मारक इंस्टीट्यूट आॅफ मेड़िकल साइंसेज, बरेली द्वारा सभी प्रकार के शुल्कों के भुगतानो, व्ययों व सभी प्रकार की सेवायें, प्रदान की गयी निविदा व प्रदान की जाने वाली निविदा के विवादो का निस्पादन उपरोक्त नामित छात्र/छात्रा के लिए होगा।
साक्षियों की उपस्थिति में, मैं अपनी स्वेच्छा से, बिना किसी जोर दवाब के, उपरोक्त उल्लेखित संबंधो में निष्पादित, घोषणा और सहमति देता/देती हूँ।
दिनांकः ....../......../..............

हस्ताक्षर:_____________________________________________________________

नाम:

अंगूठे का निशान:_______________________________________________________

That I .    S/D/O  ,    R/o    Phone No:  Neet RollNO:  All India Rank:   Neet Marks: reported for admission in your college(Shri Ram murti Smarak Institute of Medical Sciences, Bareilly) for     course session________________.
Do hereby undertake on this the ___________(Day), of __________(Month)_________(Year), the following:-

1. I hereby declare that I have been informed about all kind of fee before taking of admission of the course opted by me
2. I hereby declare that I have been informed about the rules & regulations of this Institution and I assure that I will follow them strictly, failing which I may be debarred from the institute/hostel
3. During the academic semester, I will maintain a minimum 80% attendance in Lectures & 90% in tutorials & Practical, Clinical postings & others. In no case my attendance will fall short as mentioned above even on medical and any other ground less than 80%. I have also been informed that passing marks are minimum, 50% in theory & practical separately in university exams. However in theory or practical 40% minimum passing marks is acceptable provided agregate of theory & parctical is more than 50%. If I fails to achieve 50% marks in internal assessment and 80% attaendance I will not be allowed to appear in the University Examinations.
4. I will be solemnly responsible for being detained, if I fail to achieve the eligibility criteria, for which I shall not lodge any complaint before any authority.
5. I shall keep my parents informed regarding my monthly attendance and academic performance.
6. I have been well informed not to indulge in ragging as defined by Hon’ble Supreme Court of India. The legal consequences have also been explained to me. I agree to abide not to be involved in ragging.
7. I have been well informed to use of any phone in the academic block / class room / library / hospital etc. and other prohibited areas will invite fine of Rs. 25000/- for the first time, Rs. 35000/- for the second time and I will be rusticated from the college in case I default for third time and the phone will be confiscated.
8. I hereby declare that in case, I withdraw from the course of the college after the 2nd counseling just two days before the mop up round leading to a loss of the seat to college, 50% amount of tuition fee will be deducted from my deposited amount. I also declare that deposited security amount by me to be forfeited.
9. I hereby declare that in case, I leave the college after mop up round counseling or any time during the whole course of study leading to a loss of the seat to college, I shall deposit total amount of tuition fee of the remaining course. I also declare that deposited security amount by me to be forfeited.

I  Father/Guardian of    of MBBS course of Shri Ram murti Smarak Institute of Medical Sciences, Bareilly(U.P.),  Neet RollNO:  All India Rank:   Neet Marks:  for the session______________  R/o     Phone No:
Hereby by declare on this the ____________(Day), of _________(Month)_________(Year), that the following:-

1. I hereby declare that I have been informed about all kind of fee before taking of admission of the course opted by my ward.
2. I have read and understood all the rules and regulations mentioned in Student's Manual of SRMSIMS and assure that my ward will abide by all the rules and regulations mentioned therein. I also assure that my ward will attend all the morning and evening Clinical Posting as per rules.
3. My ward will maintain a minimum 80% attendance in Lectures & 90% in tutorials & Practicals, Clinical postings & others. In no case his/her attendance will fall short as mentioned above even on medical and any other ground less than 80%. I have also been informed that passing marks are minimum, 50% in theory & practical separately in university exams. However in theory or practical 40% minimum passing marks is acceptable provided agregate of theory & practical is more than 50%. If my wards fails to achieve 50% marks in unit tests, semester & pre university exams he/she will not be allowed to appear in the University Examinations.
4. I will keep close watch on the academic performance of my ward for which I will contact the office periodically and keep myself informed on my email, mobile & by parent teacher meeting physicaly/virtual landline as given to the office. Any change of above and mailing address will be informed to the office. In case of not informing the liability will be of mine.
5. Use of any phone in the academic block / class room / library / hospital etc. and other prohibited areas will invite fine of Rs. 25000/- for the first time, Rs.35000/- for the second time and he/she will be rusticated from the college in case he/she defaults for third time and the phone will be confiscated.
6. If I withdraw the admission of my ward because of any reason, I shall pay the fee for the remaining period of the course to the Institute.
7. I will not claim any refund of the fee including Security money in case of withdrawal of admission of my ward during the programme as per clause no. 6.2 of Student's Manual.
8. My ward will complete one year Compulsory Rotatory Medical Internship from SRMSIMS, Bareilly only, as I am aware and informed that he/she will not be allowed to join any other Institution/Hospital for Internship
9. If, my ward fails to complete Internship from SRMSIMS, Bareilly, I will not be eligible to get refund of the security money which was submitted by me at the time of admission. In addition of this I will also pay an amount of Rs. 5 lac to the institute for the same.
10. Security money deposited at the time of admission will be refunded after the degree is issued by the University
11. Every genuine information as regards to ragging will be kept confidential and thoroughly acted upon immediately as per law but any false/ misleading call and wrong information by any member will invite strict action against the student
12. Any legal action/complaint, by me in this regard, will seem to be invalid