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Application Number:
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Name of the
Applicant : |
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| Date of Birth: |
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Course applying for:
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| Gender: |
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| Nationality: |
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| Belongs to: |
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| By Birth / Domicile: |
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Category: |
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| Address: |
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| City: |
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| State: |
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| Pincode: |
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| DD No.: |
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DD Amount:
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| Drawee Bank: |
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| Phone No.: |
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Mobile No.:
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| Email ID: |
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| Qualifying Exam : |
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Type of University: |
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Month / Year of Passing:
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| University last studied: |
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Completed / would be completing Internship by 30/04/2010: |
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Month / Year of completing Internship: |
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Marks Obtained in the Qualifying Examination (M.B.B.S. / B.D.S.) |
| Year |
Maximum Marks |
Marks Obtained |
Grade Obtained |
No. of Attempts |
| I Year |
600 |
394 |
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1 |
| II Year |
550 |
339 |
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1 |
| III Year |
400 |
256 |
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1 |
| IV Year |
900 |
537 |
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1 |
| TOTAL |
2450 |
1526 |
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4 |
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Declaration :
I hereby declare that the particulars given in this form are true to the best of my knowledge & belief.
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