I solemenly declare that I      S/o,D/o    Residence of     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 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:_______________________________________________________