Application Form For AdmissionD.Pharmacy/B.Pharmacy

Application Number^*

Application For^* D.Pharm B.Pharm

Academic Year^* 2019-2020

Student Name^*

Mobile Number^*

Alt. Mobile Number

Email^*

Gender^* Male Female Other

Date of Birth^*

State of Domicile^* Karnataka Non-Karnataka NRI

Seat Category^* Management CET

Hostel required^* Yes No

Mother Tongue^*

Nationality^* Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas, The Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Chad Chile China Colombia Comoros Cook Islands Costa Rica Cote D'Ivoire Cuba Cyprus Czech Republic Denmark Djibouti Dominica Ecuador Egypt El Salvador Ethiopia Finland France Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guinea Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kenya Korea Korea, North Kuwait Laos Latvia Lebanon Lithuania Luxembourg Macao Malaysia Maldives Mali Malta Mauritius Mexico Monaco Mongolia Myanmar Namibia Nepal Netherlands New Zealand Nigeria Norway Oman Pakistan Peru Philippines Poland Portugal Qatar Romania Russia Saudi Arabia Senegal Seychelles Sierra Leone Singapore South Africa Spain Sri Lanka Sudan Sweden Switzerland Syria Taiwan Tanzania Thailand Trinidad And Tobago Tunisia Turkey Uganda Ukraine UAE United Kingdom United States Uruguay Yugoslavia Zambia Zimbabwe

Caste^* SC ST BC OBC OC

Blood Group^* A-ve A+ve B-ve B+ve AB+ve AB-ve O+ve O-ve

Address

Pincode

District

State

Country

Telephone (with code)

Same As Current Address

Father`s Mobile Number

Father`s Name

Mother`s Name

Mother`s Mobile Number

Student Mobile

Guardian Number

Father/Mother Email ^*

Student Email ^*

Father PAN Number

Mother PAN Number

Student Aadhar

Residence^* Urban Rural

Name of School/College^*

Board/University^*

Reg.No^*

Year Of Passing^*

Max Marks^*

Marks Secured^*

Percentage^*

Name of School/College^*

Board/University^*

Reg.No^*

Year Of Passing^*

Group^*

Max Marks^*

Marks Secured^*

Percentage^*

I have carefully read the details regarding the admission to the D Pharm / B .Pharm course, I declare that the information provided by me in this application is true and correct to the best of my knowledge, Should it be found that the information furnished is untrue in material particulars, I know that I am liable for criminal prosecution and will forego the allotted seat, In all matters regarding my admission to the course, the decision of the College is final and binding. I am also aware that the college will not refund the fees either in full or in part, under any circumastance. If I intend to discontinue the course at any time after joining, I hereby undertake to pay the college fees and dues as applicable for the remaining years of the course. I am aware that any dispute arising out of the admission to the course will be subject to the jurisdiction of the courts of the city of Bangalore or the Honourable High Court of Karnataka.

Yes No

Yes No