ADMISSION FORM FOR UG (B.Sc.N, B.Sc.MLT, B.Pharm, B.Sc.RIT, B.Optom)-(Only for Beneficiary State Nominees / PMSSS)

* indicates mandatory fields.

Form No: 2023-719

Date: 08-02-2023

Student Details

* Attach Passport size photo Max Size: 200kb Compress photo here

First name *

Middle name

Last name

Email ID (Enter valid email Id for future correspondence) *

Age *

Date of Birth *

Sex

Male Female Transgender

Blood Group *

Identification Mark *

Community

Religion *

Category *

SC ST OBC MBC GEN

Supporting document should be enclosed

Adhar No

Details of Student's Parent

Fathers’ Name *

Occupation

Phone

Mother’s Name

Occupation

Phone

Permanent Address *

Locality/Village *

City / Town *

Police Station (P.S) *

District *

State *

Post Office *

Pincode *

Phone No.(Appilcant) *

Correspondence Address (If differ from Permanent address) *

Same As Above

Locality/Village *

City / Town *

Police Station (P.S) *

District *

State *

Post Office *

Pincode *

Phone No.(Appilcant)

Name of Local Guardian

Address

Phone No

Sponsoring State *

Allotment No/ Order No (NoX.00000/xxxxxx/xxx) *

Date *

Course applied *

Educational Qualifications *

Sl.No	Name of Exam. Passed	Year of passing	Name of Board/University	Full Mark	Marks Obtained	Percentage	Division/Grade
1
2

Subjectwise Performance in HSSLC (Science) or equivalent *

Sl No	Subject	Full Marks	Marks Obtained	Percentage
1	English
2	Physics
3	Chemistry
4	Mathematics Biology
Aggregate percentage in four subjects (in EPCB/EPCM) ( Minimum requirement 50% for Gen & 45% for other categories )

Sl.No	Subject	Full Marks	Marks Obtained	Percentage
1	English
2	Physics
3	Chemistry
4	Mathematics/Biology
Aggregate percentage in four subjects (in EPCB/EPCM) ( Minimum requirement 50% for Gen & 45% for other categories )

Extra curricular Activities (if any):

Any Addiction (Tobacco/Alcohol/ Drugs of any kind): * Yes No

Hostel Accommodation require:* Yes No

Documents required for upload:
(PDF with max file size: 200kb )

Nomination/Allotment Order. *
Marksheet of HSLC or Equivalent Examination. *
Certificate of HSLC or Equivalent Examination. *
Marksheet of HSSLC or Equivalent Examination. *
Certificate of HSSLC or Equivalent Examination. *
Caste/Tribe Certificate.
Permanent Residential Certificate. *
Fitness form (PDF or DOC with max file size: 200kb ) *
Adhaar Card (If available).

(Note: All documents uploaded by the applicant should be produced in original as and when call for verification by the Institute.)

** Compress pdf here

Declaration by the student: *

I do hereby declare that the information furnished above are true to the best of my knowledge and in the event of any misinformation detected. I shall be liable to be punished under the Rules & Regulations laid down by the Institute.

I agree