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107834

APPLICATION FORM
5 Year BS-MS Dual Degree Programme (2016)
Your Application Number is 107834. Please quote this number in any further communications.
Please take a printout of this document and bring it along with you at the time of admission.
Admission channel:

SCB

Name:

Kiran Raj R

Date of Birth:

1998-04-18

Gender:

Male

Category:

GENERAL

Person with Disability:

No

Kashmiri Migrant:

No

Address for correspondence:

Pin code:

TYPE IV QTRX MEDICAL COLLEGE

MULANKUNNATHKAVU
THRISSUR, Kerala
680596

Guardians Name:

Anitha Kumari R

Contact Number:

9497625007

Alternate Contact Number:

8089774075

Email:

kirananitharaj98@gmail.com

Percentage marks in 10+2:

93.8

Board:

CBSE

Year of passing XII:

2016

Apt. Test Center/Language:

Kochi / English

of

Opted to Float:

Subject-wise Marks
ENGLISH CORE
MATHEMATICS
PHYSICS
CHEMISTRY
BIOLOGY

Preference
IISERs:

Payment Details
Transaction ID:

92.00/100.00
91.00/100.00
95.00/100.00
95.00/100.00
96.00/100.00

1. Pune
2. Thiruvananthapuram
3. Tirupati
4. Kolkata
5. Berhampur
6. Bhopal
7. Mohali
Yes

YES-031408559403606

Amount:

INR 1500.0

Date/Time of payment:

2016-05-29 23:42:09

Undertaking from the candidate and guardian

I, Kiran Raj R, S/o, D/o, Ward/o Anitha Kumari R hereby declare that
1. The information provided by me in this application form is true and based on verifiable records.
2. I undertake to present the original documents immediately upon demand by IISER(s).
3. I understand that even if I get admitted to IISERs, it does not necessarily entitle me for a fellowship.
4. I understand that a false information provided by me in the application form or any of the supporting documents will lead to the forfeiture of
my candidature at any stage of the admission process, or thereafter.
The decision of the Chairperson, Joint Admissions Committee 2016 will be final in case of any dispute.

(Signature of the Applicant)

KIRAN RAJ R
Date:
Place:

(Signature of the Guardian)

ANITHA KUMARI R

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107834

Undertaking from the candidate and guardian

I, Kiran Raj R, S/o, D/o, Ward/o Anitha Kumari R hereby declare that
1. The above image is a scanned copy of my marksheet.
2. I understand that a false information provided by me in the application form or any of the supporting documents will lead to the forfeiture of
my candidature at any stage of the admission process, or thereafter.
The decision of the Chairperson, Joint Admissions Committee 2016 will be final in case of any dispute.

(Signature of the Applicant)

KIRAN RAJ R
Date:
Place:

(Signature of the Guardian)

ANITHA KUMARI R

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