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Pending Approval Christian Medical College, Vellore - 632002.

Online Application form - 2023
Summer Admission Courses 23031200274
1. Name of the Candidate : SIMON PRADEEP KOCHEEPPAN
2. Father's Name : PRADEEP KOCHEEPPAN
3. Father's Occupation : SENIOR MANAGEMENT / PROFESSIONAL DOCTOR
4. Mother's Name : DONA SUSAN JOHN
5. Mother's Occupation : SENIOR MANAGEMENT / PROFESSIONAL DOCTOR
Address for communication
6. House No./Street Name : EBONY C7082 SOBHA FOREST VIEW OFF KANAKAPURA
ROAD
7. Post office/ Taluk name : TALAGHATAPURA
8. City Name : BANGALORE
Only Candidate's Signature Acceptable
9. State name : KARNATAKA
10. Pin Code : 560062
11. Mobile No. : 9482564087,9606060895
12. E Mail Address : pradeepdona@yahoo.com
13. Date of Birth : 14/06/2004
I declare that all information in this form is correct. I understand that
14. Gender : Male falsification of data will result in automatic disqualification. I
hereby declare that I have read the rules & regulations regarding ragging
15. Religion : Christian as given in the Prospectus 2023-2024 and agree to abide by the same.
16. Community : Others Declaration by candidate
I SIMON PRADEEP KOCHEEPPAN child / ward of PRADEEP KOCHEEP
17. Nationality : Indian hereby consent to the collection, storage and
processing of data submitted herewith, by Christian Medical
18. State of Domicile : Karnataka College Vellore and its authorised agencies for admission,
educational and related quality purposes.
19. Marital status : Single
20. Mother Tongue : Malayalam
21. Qualifying Examination Completed : All India Senior School Certificate
22. Course(s) applied for in order of your preference
: - Basic Administrative Fee Rs. 1200
Undergraduate Degree Courses (Group A)
Pref Course Code - Course Name Category Code Applying under Minority Network Category (Y/N) Reg Fee
1 001-MBBS Minority Network (Y) 38-MALANKARA ORTHODOX SYRIAN CHURCH CATHOLICATE O Rs. 500
2
3
4
5
6
7

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

Payment Mode : PAYU Total Application Fee : Rs.1700 (Includes Basic Administrative Fee Rs.1200)
PAYU Ref. No: 20230312O0933875 Bank Transid: 307117296311 Authentication Id: 307117296311 Status: Yes Online Amount: Rs..1700