IPS ACADEMY, COLLEGE OF PHARMACY, INDORE

Rajendra Nagar, A.B. Road, Indore-452012

Telefax: 0731-4014703
Website: www.ipsacademy.org
E-mail: principal.coph@ipsacademy.org

Form No. ……………….

Date: …………………….
Affix passport
size Registration Form (2021-22)
photograph M. Pharm. Semester: I Branch:……………..
1. Name of the Student : ………………………………………………………………………………....

2. Date of Birth : 3. Gender: Male Female

4. Category : Gen OBC SC ST Other Class (tick  )

5. Religion : ………………………………………....... 6. Minority : Yes/ No (tick )

7. Present Address :……………………………………………………………………………………………......

8. Permanent Address : …………………………………………………………………………………………...

Mobile No. ……………………………...……………………………………………………………………….

9. E. mail: ………………………………………………………….. 10. Blood Group : ……………………..…

11. Aadhar Card No. : …………………………………... 12. Voter ID Card No. : ………………………..

13. Bank Account Details: Bank Name : Union Bank of India / Punjab National Bank

Branch : …………………………………………. Account No. ……………………………………….…..….

14. Father’s Name : ………………………………….. 15. Mother’s Name : ……………………………..……..

Occupation : ……………………………………. Occupation : ………………………………………..

Mobile No. : …………………………………….. Mobile No. : ...………………………………………

E. mail : ……………………………………………. E. mail : …………………………………….………

16. Local Guardian : Name :…………………………………………..……………...……………………………

Address : ………………………………………………………………………………...…………..………...

Mobile No. : ………………………………… E. mail : ……………………………………………………...

17. Record of Educational Qualifications (Attach Photocopy of Mark Sheets)

Result
Marks
Year of Percent
Roll No. Board/University Max.
Examination Passing Obtained marks
marks
X
XII
B. Pharm.
GPAT

Applicant’s Signature with date