Name in (BLOCK LETTERS)

Address for Communication

Tel No:

Mob:

Permanent Address

Tel No:

Mob:

Date of Birth

Age

Sex MaleFemaleTransgender

Nationality

Religion

Caste

Place of Birth

Details of Parents/Guardian

	Father	Mother	Guardian
Name
Occupation
Address (Use Pin code)
Tel. No.
Mob.No
Email
Income

Qualifications (+2)

Name of the Qualifying Examination
Name of University / Board
Register No				Year of Passing
Subject	Physics	Chemistry	Biology	Maths	Bio-Tech	Comp.Sci.	Total
Marks obtained
% of Marks obtained
Medium of Instruction	EnglishMalayalamHindiTamilKannada

Details of NEET Examination

2018 Roll No./Application No.
Marks Obtained
Physics (Out of 180)		Chemistry (Out of 180)		Biology (Botany & Zoology (Out of 360))
Total (Out of 720)		Percentile Score		NEET All India Rank

Details of KEAM

2018 Roll No./Application No.	2018 Qualifying Mark	Are you KEAM Eligible
		YesNo

Other Information

Name and address of the School / College Last attended
Whether the candidate was a member of Sports / NCC / NSS / Arts others (Enclose copy of certificates)

Upload Photo*
Accepted File Types: jpg, pdf,png. Accepted size:Below 1Mb.

Declaration by the Applicant

I, hereby declare that the information furnished by me are true to the best of my knowledge and belief. If any information is proven to be wrong, I hereby agree to abide by any action taken by the college including expulsion from the college.

Declaration by the Parent/Guardian

I, Hereby solemnly affirm and declare that I am fully aware of the declaration made by the applicant, my son/daughter/ward and take full responsibility for the statements made by him/her. The other statements and the information given are true, correct and complete to the best of my knowledge.

[recaptcha]