APPLICATION FORM
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PERSONAL
COLLEGE
*
INDIRA GANDHI INSTITUTE OF DENTAL SCIENCES
REFFERED BY
QUOTA
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MANAGEMENT
MERIT
NRI
DEGREE APPLIED
*
BDS - BACHELOR OF DENTAL SURGERY
APPLICANT'S NAME
(NB : PLEASE EXPAND INITIALS)
*
NAME (AS IN 10th Certificate)
DOB
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GENDER
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MALE
FEMALE
TRANSGENDER
BLOOD GROUP
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A+
A-
A1-
AB+
AB-
B+
B-
O+
O-
NATIONALITY
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CHRISTIAN
HINDU
MUSLIM
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OTHER
CATEGORY/COMMUNITY
RESERVATION APPICABLE
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NO
YES
MOBILE
*
WHATSAPP NO
LAND PHONE NO
EMAIL ID
AADHAR NO
COMMUNICATION ADDRESS
*
PINCODE
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PERMANENT ADDRESS
PINCODE
PROPOSED RESIDENCE AFTER ADMISSION
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HOSTEL
COLLEGE BUS
FATHER
CONTACT NO
FATHER OCCUPATION
FATHER QUALIFICATION
MOTHER
CONTACT NO
MOTHER OCCUPATION
MOTHER QUALIFICATION
ANNUAL FAMILY INCOME ( Rs. )
LOCAL GUARDIAN
CONTACT NO
GUARDIAN RELATIONSHIP
WHETHER PHYSICALLY HANDICAPPED
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YES
NO
DESCRIPTION ( IF YES )
WHETHER DEPENDENT OF EX-SEVICE MAN
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YES
NO
DESCRIPTION ( IF YES )
WHETHER MEMBER OF NSS / NCC
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YES
NO
DESCRIPTION ( IF YES )
REMARKS ( IF ANY )
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OTHER
MIGRATION CERTIFICATE NO
DATE
ELIGIBILITY CERTIFICATE ( IF APPICABLE )
NAME OF SCHOOL LAST STUDIED & YEAR
ALLOTMENT DATE
( BY CEE )
EDUCATIONAL DETAILS
SSLC
SCHOOL / INSTITUTION
BOARD / UNIVERSITY
REGISTER NO
MONTH OF PASSING
YEAR OF PASSING
MARKS (%)
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JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE
JULY
AUGUST
SEPEMBER
OCTOBER
NOVEMBER
DECEMBER
HSE / AISSCE / ISCE
SCHOOL / INSTITUTION
BOARD / UNIVERSITY
REGISTER NO
MONTH OF PASSING
YEAR OF PASSING
MARKS (%)
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JANUARY
FEBRUARY
MARCH
APRIL
MAY
JUNE
JULY
AUGUST
SEPEMBER
OCTOBER
NOVEMBER
DECEMBER
DETAILS
% IN PHYSICS
% IN CHEMISTRY
% IN BIOLOGY
% IN MATHEMATICS
TOTAL % PCB
NEET DETAILS
( IF QUALIFIED PLESAE CHOOSE YES )
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YES
NO
KEAM DETAILS
( IF QUALIFIED PLESAE CHOOSE YES )
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YES
NO
APPLICATION FEE DETAILS
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TRANSACTION ID / RECEIPT NO
DATE
AMOUNT
DECLARATION
I do here by agree that the forgoing information is correct and complete at the best of my knowledge and belief, nothing has been concealed / destroyed.
I Agree
NB : Fees once paid shall not be refunded under any circumstances.
APPLICATION FORM
Reffered By
Quota
Degree Applied
PERSONAL DETAILS
Name
Name(as in 10th)
DOB
Gender
Blood Group
Nationality
Religion
Category
Reservation
Mobile
WhatsApp No
Land Phone No
E Mail ID
AADHAR NO
Communication Address
Permanent Address
Proposed Residence
Hostel
Bus
Father
Contat No
Father Qualification
Father Occupation
Mother
Contat No
Mother Qualification
Mother Occupation
Annual Income
Local Gaurdian
Contact No
Relationship
Physically Handicapped
Ex-Service man
NSS / NCC
Notes
Image
Signature
OTHERS
Migration Certificate
Date
Eligibility Certificate
School last studied and year
Allotment Date by CEE
APPLICATION FEE DETAILS
Transaction ID / Receipt No
Transaction Date
Amount
EDUCATIONAL DETAILS
SSLC
School/Institution
Board
Reg No
Pass Month / Year
Mark
PLUS TWO
Name Of Examinaion Passed
School/Institution
Board
Reg No
Pass Month / Year
Mark
% in Physics
% in Chemistry
% in Maths
% in Bioligy
% in PCB
NEET DETAILS
Name of the examination
Authority
Reg No
Roll No
Rank (ALL INDIA)
Rank (Category)
Percentile Score
Total Marks
KEAM DETAILS
Year
Roll No
Rank No
Category
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