| 1.
|
Name
of the Applicant : ________________________________________________ |
| . |
(
In capital letters) |
| 2.
|
Father's
Name : ________________________________________________________ |
| 3.
|
Permanent
Home Address : _____________________________________________ |
| 4. |
Address for Communication : ____________________________________________ |
| . |
(Along with e-mail & fax) |
| 5.
|
Date
of Birth: __________________________________________________________ |
| 6.
|
Nationality
: ____________________________ Sex
( Male/Female): |
| 7. |
Passport No. : __________________________ Issued
from :_________________ |
| 8.
|
Type
of Visa : __________________________ Valid
up to : _________________ |
| 9.
|
Expected
date of arrival in India : ________________________________________ |
| 10.
|
Date
of arrival and address in India : _____________________________________ |
| . |
(If
you are in India) |
| 11.
|
Whether
self supporting or scholarship holder : ___________________________ |
| 12.
|
Academic
Qualifications : _______________________________________________ |
| 13.
|
Medical
Qualifications : _________________________________________________ |
| 14.
|
Experience
in practice : _________________________________________________ |
| . |
(if
having medical qualification/ profession) |
| 15.
|
Do
you need hostel accommodation : ____________________________________ |
| . |
(Please
attach true copies testimonials/proof for 5,6,12,13)
|
|
I hereby declare that the information given above is true. In case I am selected for the course, I shall abide by the rules and regulations of the University applicable to the course trainees and also the laws in force in the country binding on foreign nationals.
|
| Date : ____________ | | Place : ____________ |
Signature of Applicant
|
