Name of Candidate:
Date of Birth :
Mobile no :
Gender: Male Female
Email :
Nationality :
NRI :
Address :
Father / Guardian name:
Father / Guardian Mob :
Occupation:
Designation :
Mother's Name :
Occupation :
Mobile No :
Telephone no. with STD Code(off) :
(Res) :
BDS Passing Year :
Name of Institution from which passed :
University :
Aggregate % in BDS:

Permanent Registration No. with State Medical
Council/DCI:
State:
Valid upto:
State of Domicile:
Category:
Are you presently employed if yes:
Name of Employer:
MDS Speciality Preference:
Registered for MDS-NEET 2017 Yes/No:
Application No/Testing id:
If Qualified in MDS-NEET2017
Merit.No.
Percentile

How do you know about us? Newspaper/ Friend/Relative/ Education fair/ College Student
Name:

Student Pic:
Student Signature: