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Pending Approval Christian Medical College, Vellore - 632002.

Online Application form - 2021
Summer Admission Courses 21052500075
1. Name of the Candidate : SHUBHAM RAKESH
2. Father's Name : RAKESH KUMAR
3. Father's Occupation : SKILLED WORK
4. Mother's Name : SABNAM
5. Mother's Occupation : HOUSE WIFE
Address for communication
6. House No./Street Name : FLAT NO.8 PLOT NO.7
7. Post office/ Taluk name : BOPURA BRANCH POST OFFICE, DEFENCE COLONY
8. City Name : GHAZIABAD
9. State name : UTTAR PRADESH
Only Candidate's Signature Acceptable
10. Pin Code : 201005
11. Mobile No. : 9643235055,8076844415
12. E Mail Address : shubhamrksh34@gmail.com
13. Date of Birth : 15/12/2001
14. Gender : Male
I declare that all information in this form is correct. I understand that
15. Religion : Hindu falsification of data will result in automatic disqualification. I
hereby declare that I have read the rules & regulations regarding ragging
16. Community : Others as given in the Prospectus 2021-2022 and agree to abide by the same.
17. Nationality : Indian Declaration by candidate
I SHUBHAM RAKESH child / ward of RAKESH KUMAR hereby consent
18. State of Domicile : Uttar Pradesh to the collection, storage and processing of data
submitted herewith, by Christian Medical College Vellore
19. Marital status : Single and its authorised agencies for admission, educational
and related quality purposes.
20. Mother Tongue : Hindi
21. Qualifying Examination Completed : The Senior Secondary Certificate of Education
22. Course(s) applied for in order of your preference
: - Basic Administrative Fee Rs. 800
Undergraduate Degree Courses (Group A)
Pref Course Code - Course Name Category Code Applying under Minority Network Category (Y/N) Reg Fee
First 001-MBBS All India Open No Rs. 500
Second
Third
Fourth
Fifth
Sixth
Seventh

23. Has your brother / sister also applied for above course(s) this year : No

Payment Mode : HDFC Total Application Fee : Rs.1300 (Includes Basic Administrative Fee Rs.800)
HDFC Ref. No: 20210525O0658128 Bank Transid: 202114588984113 Authentication Id: 517767 Status: Yes Online Amount: Rs..1300