Krishna Institue of Medical Science Application Form
Form No.
KRISHNA INSTITUTE OF MEDICAL SCIENCES UNIVERSITY, KARAD.
Application form for (MBBS, BDS, BPTh, B.Sc Nursing)
NOTE: PLEASE READ ALL THE INSTRUCTIONS GIVEN IN BROCHURE CAREFULLY BEFORE FILLING THE APPLICATION FORM.
1.Name of candidate th First Name (As per 10 Class Certificate) Father's/Husband's Name Mother's Name Surname 2. Date of Birth D D M M 3. Nationality Status
Y Y Y Y
Signature of Candidate (within the box)
Attesed Photograph by gazetted officer or principal
(Do Not Staple or Pin the Photograph Paste it)
Photograph snapped on or after 1/1/2009
1. Indian 2. NRI 3. Foreigner 4. Sex 1. Male 2. Female
Clear Left Thumb Print (within the box)
5. Domicile
1. Maharashtra 2.Other than Maharashtra 6. SC
ST
OBC
None
7. STD Code & Telephone Number / Mobile No.
8. Marks obtained in SSC equivalent:
Marks
Out of
Year of Passing S.S.C./ equivalent:
Year of Passing H.S.C./10+2 /12 Std.
9. Marks obtained in P.C.B.(H.S.C / equivalent:)
Out of
10. Appeared 03. Mumbai
.
11. Examination Center Code: 01. Karad 02. Pune 04. Delhi 05.Ahmedabad 06. Hyderabad 07. Kottayam (Kerala)
13. DD Number of Rs.1000/-
12. DD Number Rs. 500/.
14. DD Number Rs. 1500/-
15. Form Received from:
1. KIMS, Karad
2. By post.
3. Downloaded
16. Course preferences (MBBS/BDS/B.P.Th./B.Sc.(Nursing)) i) ii) iii) 16. Candiates Address : iv)
1.Name of the school/College from which the candidate has passed/appeared for HSC/Equivalent Exam. along with its full address (Place, District, State)
District 2. Name and address of parent/Guardian Name Address
State
3.Declaration: 1. I hereby declare that the above information is true and complete to the best of my knowledge. I am aware that if any information herein is found to be incorrect or incomplete, my application form will be rejected/ admission will be cancelled. 2. If admitted to this Institution I shall abide by its rules and regulations. 3. I have
KRISHNA INSTITUTE OF MEDICAL SCIENCES UNIVERSITY, KARAD.
Application form for (MBBS, BDS, BPTh, B.Sc Nursing)
NOTE: PLEASE READ ALL THE INSTRUCTIONS GIVEN IN BROCHURE CAREFULLY BEFORE FILLING THE APPLICATION FORM.
1.Name of candidate th First Name (As per 10 Class Certificate) Father's/Husband's Name Mother's Name Surname 2. Date of Birth D D M M 3. Nationality Status
Y Y Y Y
Signature of Candidate (within the box)
Attesed Photograph by gazetted officer or principal
(Do Not Staple or Pin the Photograph Paste it)
Photograph snapped on or after 1/1/2009
1. Indian 2. NRI 3. Foreigner 4. Sex 1. Male 2. Female
Clear Left Thumb Print (within the box)
5. Domicile
1. Maharashtra 2.Other than Maharashtra 6. SC
ST
OBC
None
7. STD Code & Telephone Number / Mobile No.
8. Marks obtained in SSC equivalent:
Marks
Out of
Year of Passing S.S.C./ equivalent:
Year of Passing H.S.C./10+2 /12 Std.
9. Marks obtained in P.C.B.(H.S.C / equivalent:)
Out of
10. Appeared 03. Mumbai
.
11. Examination Center Code: 01. Karad 02. Pune 04. Delhi 05.Ahmedabad 06. Hyderabad 07. Kottayam (Kerala)
13. DD Number of Rs.1000/-
12. DD Number Rs. 500/.
14. DD Number Rs. 1500/-
15. Form Received from:
1. KIMS, Karad
2. By post.
3. Downloaded
16. Course preferences (MBBS/BDS/B.P.Th./B.Sc.(Nursing)) i) ii) iii) 16. Candiates Address : iv)
1.Name of the school/College from which the candidate has passed/appeared for HSC/Equivalent Exam. along with its full address (Place, District, State)
District 2. Name and address of parent/Guardian Name Address
State
3.Declaration: 1. I hereby declare that the above information is true and complete to the best of my knowledge. I am aware that if any information herein is found to be incorrect or incomplete, my application form will be rejected/ admission will be cancelled. 2. If admitted to this Institution I shall abide by its rules and regulations. 3. I have