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Velloore Application Form

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23 views

Velloore Application Form

Uploaded by

kevinreji2009
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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Christian Medical College, Vellore - 632002. APPLICATION No.

Online Application form - 2023


Summer Admission Courses
1. Name of the Candidate : ANNA REJI 2312132
2. Father's Name : REJI M.M.
3. Father's Occupation : SENIOR MANAGEMENT / PROFESSIONAL POLICE
4. Mother's Name : NEETHA VARGHESE
5. Mother's Occupation : SENIOR MANAGEMENT / PROFESSIONAL NURSE
Address for communication
6. House No./Street Name : MANAYATHAN HOUSE
7. Post office/ Taluk name : PADAMMALY
8. City Name : ERNAKULAM
9. State name : KERALA
Only Candidate's Signature Acceptable
10. Pin Code : 686692
11. Mobile No. : 9745565200,9447433038
12. E Mail Address : [email protected]
13. Date of Birth : 26/04/2004
14. Gender : Female
I declare that all information in this form is correct. I understand that
15. Religion : Christian falsification of data will result in automatic disqualification. I
hereby declare that I have read the rules & regulations regarding ragging
16. Community : Others as given in the Prospectus 2023-2024 and agree to abide by the same.
17. Nationality : Indian Declaration by candidate
I ANNA REJI child / ward of REJI M.M. hereby consent to
18. State of Domicile : Kerala the collection, storage and processing of data submitted
herewith, by Christian Medical College Vellore and its
19. Marital status : Single authorised agencies for admission, educational and related
quality purposes.
20. Mother Tongue : Malayalam
21. Qualifying Examination Completed : Higher Secondary Board (Other than Tamil Nadu)
22. Course(s) applied for in order of your preference
: - Basic Administrative Fee Rs. 1200
Undergraduate Degree Courses (Group A)
Pref Course Code - Course Name Category Code Applying under Minority Network Category (Y/N) Reg Fee
1 001-MBBS Minority Network (Y) 37-MALANKARA JACOBITE SYRIAN ORTHODOX CHURCH Rs. 500
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23. Has your brother / sister also applied for above course(s) this year : No

Payment Mode : PAYU Total Application Fee : Rs.1700 (Includes Basic Administrative Fee Rs.1200)
PAYU Ref. No: 20230307O0908119 Bank Transid: 306693598421 Authentication Id: 306693598421 Status: Yes Online Amount: Rs..1700

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