Christian Medical College-Vellore

10/25/2010
Provisional Reg.No.

CHRISTIAN MEDICAL COLLEGE-VELLORE
Application No

35943
SECTION I
1.Name: SIDHARTHAN Address for Communication: 9A NARAYANADAS ST KAMARAJ NAGAR PONDICHERRY PUDUCHERRY 605011 04132211292 04132211292 [email protected] 2. Sex Male 3.Date of Birth 27/05/1983 4.Religion Hindu

CHRISTIAN MEDICAL COLLEGE, VELLORE 632002 PG Application - 2011

1134057

I declare that all the information in this form is correct & any falsification of data will result in automatic disqualification

(signature)

Photo passport size only

Place:

Date: 5.Community Others 6.State of Domicile Pondicherry

SECTION II
7. Medical College For MBBS: 8. Medical College/Hospital for internship: 9. Date of (ex pected) completion of internship: 10.Best outgoing Student(enclose Certification if yes): 11. Details of Academic Training: Others Others 24/07/2006 No

(Fill this part only if sponsored previously)
Course Subject (Ex pected) Date of Completion of Course None None None None Sponsor Code Duration of obligation in year None None None (Ex pected) Date of Completion of sponsorship obligation None None None

MBBS INTERN 24/07/2006 DIPLOMA None None PG Degree/DNB None None 12.Details of work in an area of needy after internship and sponsorship obligation 13. Work ex perience at CMC, Vellore if any:(USE separate sheet if necessary)

Designation
None None None None

EmpNo

Appointing Authority
None None

Date of appointment
None None

Months of Service
None None

14. Centre for Entrance Test: SECTION III
15. Course(s) applied for in ORDER OF PREFERENCE

08-Puducherry

Preference
I II III IV

Course Code
K1-MS General Surg. C1-MD Biochemistry None None

Entrance Paper Code
PZ-General Paper PZ-General Paper None None

Sponsorship applied for Y/N
No No No No

Spon Code #1
None None None None

Spon Code #2
None None None None

16.Payment Details:(Rs.600 per preference + Rs.750 for application to be enclosed). Please enter payment details: Amount:Rs.1950 &nbspDate Bank: Place: Chalan/DD.No. 17.Eligibility Requirement fulfilled (give details if No): Yes

Send this form to the Registrar,Christian Medical College,Vellore - 632002 on or before 30th Oct 2010 with proof of payment

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10/25/2010 .

CHRISTIAN MEDICAL COLLEGE-VELLORE

CHRISTIAN MEDICAL COLLEGE VELLORE

CHRISTIAN MEDICAL COLLEGE VELLORE

ICICI BANK
(Bank Copy)

ICICI BANK
(Customer Copy, To be attached along with the application)

The Pan No. Name of Branch Date of Deposit Insitution Code Fee Collection a/c. Candidate's Name

AAATC1278N

The Pan No. Name of Branch Date of Deposit

AAATC1278N

: FC-CMC-V : 0036SLFEECOL :

Insitution Code Fee Collection a/c. Candidate's Name

: FC-CMC-V : 0036SLFEECOL :

Application Number : Amount (in figures) : Amount (in Words) :Rupees .......................................... ..................................................................................(only) Cash Details: Denomination Amount 1000 x 500 x 100 x 50 x 10 x Total

Application Number : Amount (in figures) : Amount (in Words) :Rupees .......................................... ..................................................................................(only) Cash Details: Denomination Amount 1000 x 500 x 100 x 50 x 10 x Total

Total Amount ....................... Signature/Stamp Signature/Stamp

Total Amount .......................

ICICI Bank Ltd Signature of Depositor

ICICI Bank Ltd Signature of Depositor

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10/25/2010 .

CHRISTIAN MEDICAL COLLEGE-VELLORE

OFFICE OF THE REGISTRAR CHRISTIAN MEDICAL COLLEGE VELLORE – 632 002
Dear Mr / Ms. / Dr. SIDHARTHAN
Your application number Your provisional Reg. No. is

1134057

35943

Use the application number as ID and registration number as password to download your hall ticket after 15th November 2010 from our website http://home.cmcvellore.ac.in/admissions/admin.htm Please note that your registration is provisional and will be authenticated only after the printed application form with relevant enclosures are received at our office. Please keep this safely for your reference. REGISTRAR

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