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APPLICATION FORM

Cost of application form: Rs. 100/-(For application downloaded from the Web site, candidates are instructed to pay Rs.50/- in addition to the prescribed fees for registration, otherwise it will be rejected.)


EDISON INSTITUTE OF ALLIED HEALTH SCIENCE
No:168/257, Co-operative Colony,
Mohanor Road, Namakal-637001


APPLICATION FOR REGISTRATION FOR U.G. COURSES
MEDICAL
M.B.B.S.
(Incomplete Applications will be rejected)

Year of Admission                                                :
1. Name of the Candidate                                    :
in BLOCK LETTERS
(As entered in the Higher
Secondary certificate )
(a) Expansion of Initials                                        :
(b) Name in Tamil :


2. Sex                                                                    :


3. Date of Birth (Christian Era)                              :
(Evidence should be enclosed)(The candidate should have completed 17 Years of age at the time of admission or
should complete the age on or before 31st December of the year of admission)


4. (a) Name of Father/ Guardian                           :

(b) Name of Mother                                               :
(c) Native Place                                                     :
(d) Permanent residential address                        :
(e)Present Address                                               :
Email id                                                                 :
Mobile                                                                   :
Landline                                                                :


5. (a) Religion                                                        :
(b) Community                                                       :
(c) State whether SC/ST/MBC/DC/BC/others       :
(Original community certificate should be enclosed)


6. (a) Category under which admitted to the
course (Govt./Management etc.)                           :
(b) Date of joining the course                                 :


7. Qualification and marks obtained (original mark sheet to be enclosed)
Examination
passed
Name of the
Board (State/
Central/Others)
School / College Duration Of the Course
Register No.
Month/ Year of Passing

Subject English Physics Chemistry Botany Zoology Biology/
Maths
Maximum
Marks
Marks
Obtained


8. FOR CANDIDATES WHO HAVE PASSED THE QUALIFYING
EXAMINATION OTHER THAN H.S.C. OF TAMILNADU
(a) Whether Eligibility Certificate obtained from
The T. N Dr. M.G.R. Medical University is
enclosed :
(b) Whether Transfer Certificate is enclosed. :


9. FOR CANDIDATES WHO HAVE PASSED THE QUALIFYING
EXAMINATION ABROAD

(a ) Whether Eligibility Certificate obtained :
from the T.N. Dr. M.G.R.
Medical University is enclosed
(b) Whether passport and “Student Visa” :
have been obtained
(Xerox Copies should be enclosed)


10. (a) Blood Group :
(Certificate from a competent person
should be enclosed)
(b) Contact Phone No. :
(c) Willingness to donate blood :

Note:
The following certificates in original should be submitted with the application with one
set of Xerox copy of the originals failing which candidate will not be registered for the
course.


1. H.Sc /Equivalent Mark statement(s).
2. Transfer Certificate
3. Proof for Date of Birth (in case if it is not available in T.C / Mark Statement)
4. Allotment order of the Selection Committee for the candidates admitted under
Govt. Quota
5. Migration Certificate for non-H.Sc candidates i.e., other than H.Sc of Tamil Nadu
6. No Objection Certificate (NOC) for foreign candidates.
7. Eligibility Certificate obtained from this University for non-H.Sc course i.e.,
other than H.Sc. of Tamil Nadu
8. Eligibility Certificate obtained from this University for foreign candidates
9. Community Certificate for all the category.


DECLARATION BY THE CANDIDATE


I declare that the particulars mentioned above are true and I will not claim/
ask for any change with regard to any of the particulars furnished above.
I agree to abide by the rules and regulations of the University as framed
from time to time.
Date: Signature of the Candidate

 

CERTICATE BY THE HEAD OF THE INSTITUTION


The above mentioned details are certified to be true after due verification
with the relevant documents and I hereby recommend the candidate for
registration.


Place:
Date : Signature of the Head of the Institution
Seal :

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