5/3/2017 JIPMERMBBSForm2017

ThanksforsubmittingyourApplicationForm311624whichcanbeusedforallfuture
correspondence
TransactionNo: IGABGBNWK5
Amount: 1200.00

Personal Details

ApplicationNumber: 311624

NameofTheCandidate: BADIREDDYSIVAKUMAR

Father'sName: BADIREDDYVENKATAGOPALAKRISHNA

Mother'sName: BADIREDDYTULASILAKSHMI

DateofBirth: 05/07/1999

WhetherOPH: No

Sex: Male

Nationality: Indian(ResidentIndianNational)

Puducherryresident: No

CasteState: AndhraPradesh

EntryNo: 011700991227

EmailID: gopalkrishna.bv@gmail.com

Category: OBCNonCreamyLayer

MobileNo: 9394094006

Qualication Details

Status: Completed

Subject: Physics,Chemistry,Botany,Zoology

NameofSchool/College: SRICHAITANYASAIBHARATIJUNIORCOLLEGE

School/CollegeCity: VIJAYAWADA

NameoftheBoard/University: AndhraPradeshBoardofSecondaryEducation

MonthofPassing: July

YearofPassing: 2017

Percentage: 95.8

Other Details

Parent'sEducationalBackground: FatherGraduate

Parent's/Gaurdian'sOccupation: GovernmentService

Parent's/Gaurdian'sSpecificOccupatio: TEACHER

Parent'sAnnualIncome: 6Landabove

Present Address

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5/3/2017 JIPMERMBBSForm2017

AddressLine1: 42/6/15,KOTHAPETA,RAJAHMUNDRY

State: AndhraPradesh

City: EastGodavari

Pincode: 533101

Permanent Address - to be used for verication

AddressLine1: 42/6/15,KOTHAPETA,RAJAHMUNDRY

State: AndhraPradesh

City: EastGodavari

Pincode: 533101

ID Proof Details

IDProof: AadhaarCardwithPhotograph

IDProofNo: 643996150817

Exam City Preference

PreferredExamCityOption1: Rajahmundry

PreferredExamCityOption2: Visakhapatnam

PreferredExamCityOption3: Vizianagaram

Declaration

IherebydeclarethatIhavecarefullyreadtheinstructionsandalltheparticularsstatedinthisapplicationformaretrueandcorrecttothebestofmy

knowledgeandbelief.Ifanyoftheseinformationprovidedisfoundfalse/incorrect,IshallabidebytheactionsanddecisionstakenbytheJawaharlal

InstituteofPostgraduateMedicalEducation&Research.

IherebydeclarethatIhavereadtheNonDisclosureagreementinPageNo.18oftheprospectus.

Version 12.03.00

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