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 Application Form
Please select the Program you want to Apply
Bachelor of Medicine and Bachelor of Surgery (M.B.B.S)
Bachelor of Physical Therapy (B.P.T)
Doctor of Pharmacy - Pharm.D
Doctor of Dental Medicine (DMD)
 
PERSONAL DATA
Name *: Name is required.
(As recorded in your Passport)
Sex *: Please select Male/Female.
Date of Birth : Please select Date. / Please select Month. / Please select Year. Please selectYear.
Age as on 31st December of
Admission year *: 		Age is required.
Email *: Email is required.Invalid format.
Nationality* : Nationality is required.
Marital Status : Please select Marital Status.
Mother Tongue : Mother Tongue is required.
 
Language proficiency :
Read :
Write:
Speak:
 
Contact Details
Father / Guardian's Name : Father / Guardian's Name is required.
Address : Address is required.
Father / Guardian's Email : Email is required.Invalid format.
Telephone No.*: Telephone Number is required.
Telex / Fax :
Occupation of the Father / Guardian *: A value is required.
Annual income of Father / Guardian :
 
Address for Correspondence :
Telephone No. :
Telex / Fax :
 
Passport Details :
Passport Number *: Required: Passport Number.
Date of Issue Required:Passport Issue Date.
Date of Expiry: Required: Passport Expiry Date.
Issued at : Required: Passport Issued at.
Student Visa : Please select: Required/Not Required.
Hostel Accommodation : Please select: Required/Not Required.
 
ACADEMIC PARTICULARS
School Leaving Certificate
Name & address of the
School/College :
Name of the University / Board :
Reg. No. :
Number of attempts for passing :
Year of passing :
 
Examination Passed Higher Secondary / Equivalent exam ( 12 grade)
Name & address of the
School/College :		 Name & address of the
School/College is required.
Name of the University / Board : Name of the University / Board is required.
Reg. No. : Register Number is required.
Number of attempts for passing : A value is required.
Year of passing : Year of passing is required.
 
Any Higher Examination
Name of the Course/Degree :
Name & address of the
School/College :
Name of the University / Board :
Reg. No. :
Number of attempts for passing :
Year of passing :
 
English language proficiency
TOEFL / IELTS : Please select: TOEFL/IELTS.
Score : TOEFL/IELTS Score is required.
 
NOTE :INCOMPLETE APPLICATION FORM WILL NOT BE ACCEPTED
 
 
 
 ADMISSIONS OPEN
Bachelor of Medicine and Bachelor of Surgery (M.B.B.S)
Doctor of Pharmacy (Pharm.D)
Doctor of Dental Medicine (DMD)
Bachelor of Physical Therapy (B.P.T)
Masters in Clinical Pathology (M.S)
Masters in Toxicology (MS)
Masters in Public Health (MPH)
Diploma in Public Health
Diploma in Toxicology
 
 

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