Application For Admission To Dental Courses 2017-18


Applying for




Specialization Prefered


First Preference
 

Second Preference
 

Third Preference
 

Personal Details


Name of the Applicant
(AS IN DEGREE CERTIFICATE)
 

Father/Guardian
 

Date of Birth
 
 

Place of birth
 

Nationality
 

Domicile
 

Gender
 

Community

Non-Resident Indian (NRI)

Permanent Address


Door No.
 

Street
 

Locality
 

City

Country

Province/State

Region/District
 

Pincode
 
 

Address for Communication


Door No.
 

Street
 

Locality
 

City

Country

Province/State

Region/District
 

Pincode
 
 

Contact Details


Landline Number
 
Use hyphen or '/' to seperate country/region code.

Mobile Number
 

Alternative/Father Mobile No
 

Email Id
 
 

Qualifying Examination Passed


Degree


Year of Admission
 

Date of CRRI Commencement
 

Date of CRRI Completion
 

Year of Completion
 

Name of Institution

Institute recognized by MCI
 

Degree

PG Diploma


PG Diploma in

Year of Admission
 

Year of Completion
 

Name of Institution

MBBS / BDS / PG Diploma Marks


Year Month Year Marks Obtained Maximum Marks Percentage of Marks No. of Attempts
I MBBS / BDS
II MBBS / BDS
Final MBBS I / III BDS
Final MBBS II / IV BDS
Aggregate
PG Diploma (if relevant)

NEET Exam Details


NEET Roll Number

NEET All India Ranking

NEET Marks Obtained

Payment Details


Amount

Payment Mode

Demand Draft No.

Drawn On Bank

On Date
 



Document Uploads


Photo of the Candidate *

 

MBBS/BDS University Graduation Certificate (pdf)


MBBS/BDS Mark List / Certificate (pdf)


MBBS/BDS Internship Completion Certificate (if completed) (pdf)


MCI/DCI Provisional Registration Certificate (pdf)


Community Certificate for SC / ST / OBC (pdf)


NEET (PG) 2017 Results Certificate (pdf)


Signature of the Candidate (jpg) *

 



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