INDIAN INSTITUTE OF ALLIED HEALTH SCIENCES

Email: info@iiahs.in, website: www.iiahs.in

ADMISSION FORM
(Fill in BLOCK letters only)

Photo
Enrollment No:

Academic year

Course and Specialty Applied for D I A B E T I C E D U C A T O R

Name of the Applicant (as in the Birth Certificate or Marks card of Standard X Exam)

I Q R A

Father’s Name H A R U N K H A N

Sex: Male Female Date of Birth & Age: Date Month Year Age

2 0 0 6 1 9 9 5 2 8

Nationality I N D I A N

Address for Correspondence (Do not repeat name)

H N O. 6 0 4 G U L S H A N C O L O N Y
B E H I N D P N B B A N K
M U R A D N A G A R

Phone No. Mobile No. 6 3 9 5 2 5 6 8 1 9

Email ID: iqrasaifi817@gmail.com

Details of Educational Qualifications (From X Standard onwards)

S.No. Name of the Month & Name of the School Name of the Subjects % Obtained
Qualifying Year of / College University /
Exam. Passing Board
1 M. Sc. (Food 2018 C.C.S. Univ C.C.S. Univ. Food & Nutrition 1st Div.
& Nutrition) Meerut Meerut
B.Sc. (Home 2016 C.C.S. Univ. C.C.S. Univ. Clinical Nutrition & 1st Div.
2 Science) Meerut Meerut Dietetics
3 Intermediate 2013 JLM School U.P. Board
Hindi, Sanskrit, Eng., Home 1st Div.
Sci., Economics, Sports
Hindi, Eng., Home Sci., 1st Div.
4 High School 2011 JLM School U.P. Board Science, Social Sci., Dwg
Employment Details:

a) Employed: (Tick) Yes No

b) Designation Dietician

c) Name of the Company / Institution Yashoda Hospital

d) Address:
Y A S H O D A H O S P I T A L C A N C
E R I N S T I T U T E S A N J A Y N
A G A R G H A Z I A B A D

Fees Payment Particulars:

a) Cash b) b) DD c) Cheque

a) Name of the Bank ONLINE PAYMENT PAID

b) DD / Cheque Number

c) DD / Cheque Date

Rupees (in words)

Rs. Six Thousand Only

DECLARATION

I hereby declare that, the information furnished herein are true and correct to the best of my knowledge and
belief. I have read the prospectus and the rules and regulations of the University. In case any information
furnished is found Incorrect, at any stage I agreed to forego the claim for admission.

Terms & Conditions:

a) Xerox Copy of Mark sheets and Certificates in proof of all examination passed should attach.
b) The Application form along with the Bank Draft should be sent to the Institute through Courier/Speed
Post.
c) Fees once paid is non refundable under any circumstances.
d) Payment by D.D. & Cheque should be made in the favore of Indian Institute of Allied Health Sciences
Payable at Delhi.
e) Cash payment receivable against money receipt at Corporate Office Only.
f) In Case of any Disputes jurisdiction will be at New Delhi/ Delhi Corporate Office Only.

Date:
Place: Muradnagar

(Signature of the Branch Head) (Signature of the Applicant)