M.B.B.S / B.P.T
BACHELOR OF MEDICINE AND BACHELOR OF SURGERY (M.B.B.S)
BACHELOR OF PHYSIOTHERAPY (B.P.T)
A. PERSONAL DATA

  Name *:
  Sex *:  
  Date of Birth : / /
  Age as on 31st December of academic Year *:
  Email *:
  Nationality* :
Marital Status :
  Mother Tongue :    
  Language proficiency :    
 
Read :
Write:
Speak:
 
Father / Guardian's Name & Address *:
 
Telephone No.*:
Telex / Fax :
Occupation of the Father / Guardian *:
 
Address for corresponding :
 
Telephone No*.:
Telex / Fax :
Annual income of Father / Guardian :
  Passport Details :  
 
  Passport Number *:   Date of Issue :
  Date of Expiry:   Issued at :
           
  Student Visa :  
  Hostel Accommodation :  
     
B. ACADEMIC PARTICULARS
Examination Passed
Name & address of the School/College
Name of the University / Board
Reg. No.
No. Of attempts for passing
Year of passing
a . School Leaving Certificate
b. Higher Secondary / Equivalent exam ( 12 grade)
c. Any higher Examination
 
C. QUALIFYING EXAMINATION DETAILS (H.S.C. or Equivalent)
  a. Name of the Examination passed* :
  b. Name and Address of the Institution* :
  c. University / Board to which attached*:
  d. Total marks secured in all subjects *:
Marks obtained in the following subjects in the qualifying examination :
 
Physics
Chemistry
Biology
Aggregate % in Physics Chemistry & Biolog
English
Maximum marks
Actual marks obtained
Percentage of marks
 
D. DECLARATION BY STUDENT
  I have carefully read the instructions given in the prospects and agree to abide by the decision of the Institute's authorities regarding my selection for the programme. I certify that the particulars given by me in this application form are true to the best of my knowledge and belief
  Place :
  Date : Signature of the applicant
  NOTE :INCOMPLETE APPLICATION FORM WILL NOT BE ACCEPTED