<p>SREE NARAYANA INSTITUTE OF MEDICAL SCIENCES MANAGED BY GURUDEVA CHARITABLE TRUST Chalakka, N. Kuthiyathodu P.O., Aluva -683 594.Ernakulam District, Kerala Phone No.0484-2479199/2573063/2573023/24,Fax No.0484-2478093 Website: www.snims.org, E-mail: [email protected] </p><p>APPLICATION FORM FOR ADMISSION Affix POST GRADUATE DEGREE COURSE 2016 (MD PHARMACOLOGY) Passport size photograph</p><p>Application Number /2016 </p><p>1. Name of the Applicant (in block letters) (As entered in S.S.L.C. or equivalent) First Name Middle Name Last Name</p><p>2. Name of the Parent /Local Guardian Relationship with Contact Number the applicant </p><p>3 Name of the Local Guardian Relationship with Contact Number the applicant </p><p>4 a)Age (as on 31.12.2015) b) Date of Birth (evidence of age proof to be attached) c) Gender(M-Male,/F-Female) D D M M Y Y Y Y</p><p>5. Nationality : Indian If Others (Specify)</p><p>6. a) Religion b)Caste</p><p> c) Indicate the category to which you belong SC ST OBC/SEBC Others (Please Tick ) 7. Permanent Address:</p><p>P O </p><p>Town/City District PIN</p><p>State PIN 8.Present Address (Address for communication, if different from permanent) </p><p>P O </p><p>Town/City District District </p><p>State Country PIN</p><p>9. E-mail Address (must be active) </p><p>10. Phone Number (with STD Code)</p><p>11. Mobile Number</p><p>12. Father’s / Husband’s Name Occupation</p><p>13. Mother’s Name Occupation</p><p>14. Annual Family Income Rs.</p><p>15. Name & location of the school where MBBS was completed</p><p>16. Details of Qualifying Examination (MBBS) Year of passing Name of college Register No.</p><p>17. Marks obtained in Qualifying Exam (Attach self attested copy of the Mark list): (MBBS)</p><p>Subject Marks Maximum % of Marks Year of Passing Scored marks 1st year MBBS 2nd year MBBS 3rd Year MBBS (Part I) 3rd Year MBBS (Part II) Total Marks 18. Details of MBBS Registration: Name of Council Registration Number </p><p>19. Details of Kerala Entrance Examination : (Attach self attested copy of the result print) Total Maximum Name of Examination Rank Marks Marks</p><p>20. Details of other Entrance Examinations : (Attach self attested copy of the result print) Total Maximum Name of Examination Rank Marks Marks</p><p>21. Joint Declaration by the Applicant & Parent/Guardian:</p><p>We,…………………………………………….. (Applicant) &………………………………………….. (Parent/Guardian) do hereby declare that all the information furnished above are true and correct. We will obey the rules and regulations of the Institution, if admitted. We promise to submit all certificates and documents in original at the time of admission failing which the admission will be liable for cancellation.</p><p>Name & signature of the applicant Name & signature of the parent/guardian</p><p>Place: Date:</p><p>FOR OFFICE USE ONLY 1) Name of College where Qualifying Examination (MBBS) completed:</p><p>Total Marks : Ist MBBS Marks : 2nd MBBS marks:</p><p>3rd MBBS (Part I) Marks: 3rd MBBS (Part II) Marks : </p><p>2)Name of Entrance Examination : </p><p>Entrance Marks: Entrance Marks Percentage: </p><p>Principal Date: ------SREE NARAYANA INSTITUTE OF MEDICAL SCIENCES ACKNOWLEDGEMENT OF APPLICATION MD Pharmacology– 2016- 2017</p><p>Name of the Applicant :……………………………………………….</p><p>Received the application on …………………….Time………………</p><p>Received DD along with application. </p><p>Signature & Seal</p>