AKSHARA INSTITUTE OF PHARMACY

PHOTO OF STUDENT*

COURSE*

D PHARMA

NAME*

First NameLast Name

STUDENT TYPE*

ACADEMIC YEAR*

MODE OF ADMISSION*

GOVERNMENTPRIVATE

GENDER*

MALEFEMALEOTHER

DATE OF BIRTH*

AGE*

NATIONALITY*

INDIANNON RESIDENT INDIANNON INDIAN

REGIONALITY*

KARNATAKANON KARNATAKA

COUNTRY OF RESIDENCE OF NON RESIDENT INDIAN

COUNTRY OF RESIDENCE OF NON INDIAN

RELIGION*

CATEGORY*

IF OTHERS PLEASE SPECIFY THE CATEGORY *

TYPE N/A IF ALREADY SPECIFIED IN THE CATEGORY

FATHER NAME*

MOTHER NAME*

CURRENT ADDRESS*

Street Address

Street Address Line 2

CityState

Zip CodeCountry

PERMANENT ADDRESS*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

STUDENT EMAIL*

example@example.com

STUDENT CONTACT NUMBER*

Please enter a valid phone number.

PARENT CONTACT NUMBER*

Please enter a valid phone number.

LOCAL GAURDIAN NAME*

LOCAL GAURDIAN CONTACT NUMBER*

Please enter a valid phone number.

10TH CLASS*

BOARD

SCHOOL

PERCENTAGESTATE / PROVINCE

12TH CLASS*

BOARD

SCHOOL / COLLEGE

PERCENTAGE STATE / PROVINCE

SUBJECTS CHOSEN IN 12TH CLASS*

PHYSICSCHEMISTRYMATHEMATICSBIOLOGY

PHYSICS*

CHEMISTRY*

MATHEMATICS

BIOLOGY

AVERAGE PERCENTAGE OF PCM / PCB*

10TH MARKS CARD*

12TH MARKS CARD*

TRANSFER / MIGRATION CERTIFICATE*

ADDRESS PROOF*

I blanks* PARENT OR GAURDIAN OF blank*BEING ADMITTED TO D PHARMA COURSE IN AKSHARA INSTITUTE OF PHARMACY , PARAGODU - 561207 , HERE BY DECLARE THAT THE INFORMATION PROVIDED BY THE APPLICANT IS TRUE AND CORRECT AND IF AT A LATER DATE IT IS FOUND THAT THE INFORMATION PROVIDED IS INCORRECT OR FALSE , I UNDERSTAND THAT I WILL LIABLE FOR ALL LEGAL CONSEQUENCES . I AM RESPONSIBLE FOR THE GOOD BEHAVIOUR AND CONDUCT OF THE APPLICANT DURING THE PERIOD OF STUDY OF THE COURSE

I blanks* DAUGHTER/SON OF blank* HEREBY DECLARE THAT THE INFORMATION FURNISHED ABOVE IS TRUE TO THE BEST OF MY KNOWLEDGE. I PROMISE TO ABIDEBYTHE RULES & REGULATIONS FRAMED BY THE COLLEGE AUTHORITIES AND ALSO DECLARE THAT I AM LIABLE FOR ANY DISCIPLINARY ACTION TAKEN BY THE COLLEGE AUTHORITIES IN CASE OF ANY VIOLATIONS OR ANY DEFAULT FROM MY SIDE.I HEREBY UNDERTAKE TO MAINTAIN STRICT DISCIPLINE AND CODE OF CONDUCT.

SIGNATURE OF PARENT / GAURDIAN*

SIGNATURE OF STUDENT*

Please verify that you are human*

DASHAPRAMATHI EDUCATIONAL TRUST (R)

AKSHARA INSTITUTE OF PHARMACY