2-year Advanced Post Graduate Diploma in Emergency Care

(Affiliated to Osmania University, Hyderabad-500007)

Affix recent
photograph &
Entrance Examination Application form sign across the
photograph
Last date for submission of application form : 29th May, 2010 (Do not
pin/stapple)
Date of Entrance Examination : 5th June, 2010

Downloaded application must accompany a demand draft for Rs.500/- (non-refundable) drawn in favour of
“GVK Emergency Management and Research Institute, payable at Secunderabad” towards Prospectus and
Examination Fee.

Note: Before filling up the Application Form, the candidates are advised to carefully go through the
instructions given in the advertisement/website http://www.emri.in/edu

Particulars of the Fee paid: Name of the Bank:_________________

(Please write your name
on the backside of the Demand Draft) Issue Branch : _________________

DD No…………………………. Date:…………………… Amount:Rs.500/-

1. Name of the Candidate (in Capital Letters as entered in the qualifying examination)

______________________________________________________________________________________

2. Name of the Father/Mother :__________________________________________________________

3. Gender [Male/Female] :__________________

4. Date of Birth (Attach Xerox copy D D M M Y Y Y Y

of S.S.C. Certificate)

5. Category (put a tick mark) 6. Minority status (Put a tick mark)

ST SC BC-A BC-B BC-C BC-D BC-E Others Christian Muslim Linguistic

7. Particulars of study from the qualifying examination:

School/College/ Year of
Course/ Class Group Place % Grade
University Passing

Degree

Intermediate

Class X
8. Related Experience:

Exp
S.No. Organization Designation Phone No. Address
(in months)

9. Address for Communication in Block Letters:_____________________________________________

____________________________________________________________Pin Code__________________

City:______________________ State: _______________________ Country: _______________________

Phone Number with STD Code:_________________________ Mobile Number:____________________

Email ID:___________________________________________

10. Permanent Address (leave blank if it is same as above)______________________________________

____________________________________________________________Pin Code__________________

City:______________________ State: _______________________ Country: _______________________

Phone Number with STD Code:_________________________ Mobile Number:____________________

Email ID:___________________________________________

I hereby solemnly affirm that the above information is correct and I am aware that my admission is liable to be
cancelled at any time in case any information is found to be incorrect. I have gone through and understood
the Rules, Regulations and instructions of Admission procedure

Date:________________________ Signature of the Candidate

---------------------------------------------------------------------------------------------------------------------------------------------

CHECK LIST

Arrange the application and enclosures in the following order:

1. Application Form
2. Xerox copies of Qualifying Examination and SSC

Submit the filled in application to

COORDINATOR,
Advanced PG Diploma in Emergency Care (APGDEC),
GVK Emergency Management and Research Institute,
Devar Yamzal, Medchal Road, Secunderabad – 500 014,
Andhra Pradesh, India, Phone : 040 91-40-23462391