Trivandrum

DD

Jawaharlal Institute of Postgraduate Medical Education & Research

Institution of National Importance Dhanvantri Nagar, Puducherry - 605006, India
Online Application form for Admission to Jipmer MBBS Course - July 2012 Session.

Application No

558375
KALEESWARI R M.RAJASEKAR R.VIJAYALAKSHMI No OBC 17-Jun-1995

1. 2. 3. 4. 6. 8. 10. 11. 12. 14. 15. 16. 18.

Name (as given in Xth / XIIth Std Certificate) Father's Name Mother's Name Are you an OCI Category Date of Birth (as given in Xth / XIIth Std Certificate) Address for Communication Pincode Telephone Number Email Address School Name & Address Choice 01 Payment Mode. DD NO: Branch

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ou r

Ph ot

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5. 7. 9.

Religion Whether OPH Gender

Hindu No Female

R.KALEESWARI,D/O M.RAJASEKAR,11-2-3B,RAJ NAIDU STREET,PERAIYUR TALUK,T.KALLUPATI 625702 04549272370

13.

Mobile Number

9585793272

kaleeswari9506@gmail.com GANDHINIKETAN G.VENKATACHALAPATHY HIGHER SECONDARY SCHOOL,T.KALLUPATTI(625702)MADURAI DISTRICT Trivandrum DD Payment 784398 PERAIYUR(1016)

17.

Choice 02

Puducherry 1000 CANARA BANK

Payment Amount. Bank

Declaration Kindly Check & agree with the declaration mentioned below before submitting Registration Form. UNDERTAKING/DECLARATION: I solemnly affirm that the information furnished above is true and correct in all respects. I have not concealed any information. I realise that if any information furnished herein is found to be incorrect or untrue; I shall be liable to civil/criminal prosecution and also forgo my claim to the seat in the institute. Futher, I affirm that no proceedings in respect of any civil/criminal offence alleged to have been committed by me are pending before any criminal court in India. I agree to abide by the rules and regulations governing this examination and as contained in the prospectus. I agree to abide by the rules and regulations governing this examination and as contained in the prospectus.

Candidate Signature

Parent / Guardian Signature

Application without these two signatures & certificates in respect of Category & demand draft where applicable will be summarily rejected without any further correspondence Application should reach JIPMER on or before 01 May 2012 16.30 Hrs IST.