err82015, ‘Applicaton to MBBS Couse 2015-16, MES MEDICAL COLLEGE, PERINTHALMANNA Application to MBBS Course 2015-16 PRINT rot apotcable with NA, Nor (tra) a the ease may be. 53. Use only "BLOCK LETTERS tia the appation frm 4. Inoomelte and or unslonedepnkation and epplkaton nat accompanied by DD towarésapplation fee and documents i proof cis [APPLICATION NUMBER es\MaBs\2015\6692 1 | Name of aplcnt (astm Schoo! Record) | MONAMMED RIZWAN KP 2 | ate of Beth in Chetan Era 18/06/2996 3 [sex MAE name lation ausiness 75000 Contact aepione/ mie number(s) Contac telephone / mesie umerts) 9426089999 emai iewantheplayerBgmal.o cast Relgen community 7 | cast, ragon and community Relgion Denomination Cateoory Forseats | yes served fr Specie category, oroup 8 | pecty category group 8 on de Prospectus) ——ers Detal o DO produced towards Aplcaton Fee [5.1000 9 [bamand batt Number ane Date DON: 482316 DO bate: 18/08/2015 Name of Beni & Branch Name: FEDERAL BANK ‘Branch: TALIPARAMBA 10 Details of Qualifying Examination Name of Scheoiolege [CHALDEAN SYRIAN HIGHER SECONDARY SCHOOL THRISSUR Name of Bosa/Universty BOARD OF HSE KERALA fies JUsershmohammad%20razwiniDowrlcads/Apeicaton% 20% 20M BBS%Z0C oxse%202016- 1 hi 1err82015, ‘Aplicaion to MBBS Couse 2015-16, Subject Marks Obtained Maximum Marke por Enaten| 74 200 ort It Aational Language sno 200 200 att Optional Subjects Physics 183 200 Sioleoy Betechneteay 293 200 1 Details of marks obtained in Medical Entrance Examination a2 960 reao [oe 1 nerey delve tat Declaration by the applicant semisons and agree to abide ty ther. aso afm that fle elgbity requirement fo the courses ape. particulars stated inthis appleation frm are true to the best of my knowlege and beet. have read and undestoo all provisions of Incorec or untr information or suppression cr distortion a ny fac ke eciatonal qualiicaton, marks, natal, et. by me n this apsleaton, {understand ‘ot my semison/desee fll for canceltion. {further understand thet my admission purely provisional subject tothe vera a the eli constins Space for Office Use PRINT fies JUsershmohammad%20razwiniDowrloads/Aprcaton% 200% 20M BBS%Z0C ouse%202015-16 hi