Registration Form for BDS Course
Admission 2017
Name of Student:  
  Date of Birth :
  Mobile no :
Gender: Male Female
Email :
Nationality :
   NRI :
Address :
Father / Guardian name:
   Mob :
Address :
Occupation:
   Designation :
Mother's Name :
  Occupation :
  Mobile no :
Telephone no. with STD Code(off) :
   (Res) :
State of Domicile :
  Name of the Schoollast attended :
Aggregate % in qualifying (10+2) Exam :
   Board/ CBSE/ ICSE /Others :
Aggregate % in PCB :
  Aggregate % in English :
Medium of Education:
   (HINDI/ENGLISH)
Category/ Caste:
If appeared in AIPMT Entrance :
  (Roll no.) :
  (Rank) :
  (Form no/Roll no) :
  (Rank) :
Do you need Bus Facility: Yes/ No :
   Do you need Hostel Facility: Yes/ No :
Local Guardian's Name & Address :
Contact No.(off) :
  (Res) :
  (Mob.) :
Select image to upload:       
Select image to upload:       

NOTE: Applicants are required to deposit Rs.1000 as Enquiry Guidance fee.
  • Admission Fee structure will be strictly as per DMER/Government of Haryana/Pt. B.D Sharma University of Health & Sciences Rohtak/DCI-2017.
  • This is just the Enquiry form, not the application for Admission.

*This is just the registration/enquiry form, not the application for admission.