Application No : PIMS-CHS99

Health Sciences Programs (Please mention your course as per your perfernce ( 1 , 2 & 3)*

I. Personal Details

Name of the Candidate (as given in the degree certificates / SSLC) *

Date of Birth & Age*

Religion*

Caste Name*

Caste Group (As per caste certificate)
(General/SC/ST/OBC/MBC/BC etc)*

Blood Group*

Aadhar Number*

Name of Father*

Occupation of Father

Name of Mother*

Occupation of Mother

Nationality*

Address for Communication*

Candidate Mobile Number and email ID (Compulsary)*

Parent's Mobile Number *

General education

Slno	Qualification	Year of passing	University/ Board	% of marks / grade / class
	*

Marks in H.Sc. / Pre University / Any equivalent

Slno	Subjects	Max. Marks	Marks Obtained	% of marks
a

Note:

The students those who are awaitng for the Board Examination results, kindly update the marks in the same application form after the declaration of the result

Self Declaration:

The above details furnished are true to my knowledge and I am responsible for any discrepancy if found and thier consequences.

Date

15/05/2024

Place*

Passport Size Photo*
size should be height--> 200px and width --> 200px allowed formats (PNG, JPEG, JPG)

Signature*
size should be height--> 150px and width --> 250px allowed formats (PNG, JPEG, JPG)