SELECTION COMMITTEE FOR DIPLOMA COURSES

IN INDIAN MEDICINE AND HOMOEOPATHY, CHENNAI

CHENNAI-106.
APPLICATION FOR ADMISSION TO THE DIPLOMA IN INTEGRATED PHARMACY /
DIPLOMA IN NURSING THERAPY COURSES - 2016-2017
------------------------------------------------------------------------------------( For Office use only)
Community

Cut off

Rank

Application Register No.

( To be filled by the candidates own handwriting )

1.Candidates Name in full:

(in block letters)

Space for
Photograph

2. Name of the Parent / Guardian :

(To be Self attested )

3. Address for communication:

-------------------- ------------ ------------------ ------------------------------------------ ----------------- ------------- ------------------------------------------------------------ ------------- -------------- --------------------- -Pincode :
Contact phone No:

Mobile:
4(b)
4(b).Sex ( ) :

4.(a) Date of Birth :

Male / Female

5.Nationality ( ) : Indian / Others

6(a). Nativity ( ) : TN /Others

6(b). District:

7.Religion
8. Community ( )

O.C

B.C

B.C.M

M.B.C./D.C

S.C

S.C.(A)

S.T.

8(a). Caste :

Applicants signature.

9. Are you applying under any Special Category ( ) : YES / NO

(Mentioned in Para 15 of Prospectus. If yes, specify the Category code and number with enclosure
of Documents. If not filled up, claim to special category will be disallowed and any request

later will not be entertained)

Sl.No.
(i)

Special category Code number

Name of the Special category

(ii)

10 (a). +2 Reg.No. :

10 (b). Year of Passing :

11. Marks obtained in +2 Exam:

(First appearance only)

Subjects
Physics

Max. Marks

Marks secured

Chemistry
Biology
Botany
Zoology

Signature of the applicant

DECLARATION BY THE APPLICANT AND PARENT
The information furnished above is true and correct. The original certificates will be produced at the
time of admission or on demand. In case, any information furnished above is found to be incorrect,
we agree to forego the claim for admission besides making us liable for criminal prosecution.

Date:

Signature of Parent / Guardian.

Signature of Applicant.

TO ENCLOSE THE FOLLOWING CERTIFICATES :

a) Self Attested copy of +2 Mark sheet.
b) Self Attested copy of latest Transfer Certificate.
c) Self Attested copy of SSLC Mark sheet.
d) Self Attested copy of Permanent Community Certificate.
e) Two latest conduct certificates in Original (One compulsorily From Head of
the institution last studied)
f) Self Attested copy of Nativity certificate for those who have not studied from 8th
Std to +2 (Continuously without break)
g) Self Attested copy of certificates in support of claim for special category
Wherever applicable.