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Application for Medical Course Admission

Pritam Panigrahi has applied for admission to medical and dental programs offered by Manipal University. He has provided his basic personal details such as name, email, address, and contact information. Regarding his education qualifications, he has completed his 12th grade from CBSE board in 2015 and scored well in the qualifying exam. He has made the application fee payment of Rs. 1600 online and confirmed that he meets the eligibility criteria for the programs applied. In the declarations, he has affirmed that all information provided is true and he agrees to abide by the admission policies of the university.

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Pritam Panigrahi
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9 views3 pages

Application for Medical Course Admission

Pritam Panigrahi has applied for admission to medical and dental programs offered by Manipal University. He has provided his basic personal details such as name, email, address, and contact information. Regarding his education qualifications, he has completed his 12th grade from CBSE board in 2015 and scored well in the qualifying exam. He has made the application fee payment of Rs. 1600 online and confirmed that he meets the eligibility criteria for the programs applied. In the declarations, he has affirmed that all information provided is true and he agrees to abide by the admission policies of the university.

Uploaded by

Pritam Panigrahi
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Application Number:

2030749

PROGRAMS
Course Groups - [Courses]

Medical, Dental & Pharmacy - [BDS & MBBS]

Test Centers

Delhi,Gurgaon

BASIC INFORMATION
First Name

Pritam

Email ID

[Link]
i@[Link]

Last name

Panigrahi

Mobile Number

9582782220

Parent's Name

Dr. Bijaya Ketan


Panigrahi

Phone Number

9818275326

Gender

Male

Address

Warden house
Aravali hostel
IIT delhi , Hauz khas

Nationality

Indian

Student Photo

Student Signature

Pg 1 of 3

EDUCATION QUALIFICATION

University Name

Suraj Bhan DAV public Qualifying Exam


school

12th

Board/University

cbse

Year of Passing

2015

ONLINE(CCAvenue)

Payment Amount

1600

PAYMENT DETAILS

Payment Type

OTHER INFORMATION
Date of Completion of
Internship

Are you a diploma


holder?

Exam Name

Exam Score

Registration No:

Completion Year

I confirm that I fulfil the eligibility criteria for the course I am applying for.
I understand that no refund will be made on the application fee if I am not eligible for the programmes I am applying for.

Pg 2 of 3

DECLARATIONS

I hereby declare that all the particulars stated in this application form are true to the best of
my knowledge and belief. I have read and understood all provisions of admissions and agree
to abide by them. I also affirm that I fulfil the eligibility requirements for the course/s applied.
In the event of submission of fraudulent, incorrect or untrue information or suppression or
distortion of any fact, like educational qualification, marks, nationality etc. I understand that my
admission/degree is liable for cancellation. I further understand that my admission is purely
provisional subject to the verification of the eligibility conditions. NOTE: 1. Please keep a copy
of the filled in application for future reference. 2. Application number must be quoted in all future
correspondence. 3. Please mail the printed copy of the completed application form along with
the DD/Challan (if payment is not via Credit / Debit Card) to: The Director, Admissions, Manipal
University, Manipal - 576104

Pg 3 of 3

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