Microsoft Word - BPT application.doc



APPLICATION FORM FOR ADMISSION TO B.P.T. COURSE FOR THE YEAR 2020-2021

(Please fill in block letters only)

| |Name of the candidate (As per | | |

|1. |SSLC/10th Marks Card) | | |

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| | | |PASSPORT SIZE PHOTO |

| |Gender (tick ⎫) | | |

|2. | |Male Female Others | |

| |Date of Birth | |

|3. | |Mother Tongue: |

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|4. |Blood Group: |Aadhar Card No: |

| |Father’s name | |

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| |Mother’s name | |

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| |Postal address for communication: Rural Urban |

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| |Present Address: |Permanent Address: |

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| |Pin Code: State: |Pin Code: State: |

| |a) Ph No. (Landline) with STD Code: c) Mob. No. Father : |

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| |b) Mob. No. (Student): Mother: |

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|9. |Email ID |Student: |

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| |Father: |Mother: |

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|10. |Date of passing II PUC/12th Examination: |Reg No: |

| |Name of the Board | |

|11. | | |

P.T.O.

| |Marks Obtained in II PUC/ Equivalent examination |

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| |Total Percentage in PCB:………………… |

| |Category (tick ⎫) Caste: Sub Caste: |

|13. | |

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|14. |Nationality : |Religion: |

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|15. |Father’s Occupation / Profession: |Mother’s Occupation / Profession: |

DECLARATION OF THE CANDIDATE

I hereby declare that, all the information furnished above are true and correct to best of my knowledge and also agree that my admission may be cancelled in the event of any falsification of information produced and fees paid may be forfeited.

Signature of Father/Mother/Guardian Signature of the Candidate

Place:

Date:

OFFICE USE ONLY

Date of Admission: Fee Receipt No: Date:

Original documents submitted:

|Sl. No. | | | |

| |Name of the Certificate |Yes |No |

|1 |X marks card | | |

|2 |XII marks card | | |

| |Eligibility certificate issued by Shri Dharmasthala Manjunatheshwara University, Dharwad.(For non-Karnataka candidates & | | |

|3 |CBSE & other 12th examination board candidates) | | |

|4 |Physical fitness certificate | | |

|5 |Transfer / Leaving certificate | | |

|6 |Character certificate | | |

| |Migration certificate (for non-Karnataka candidates & CBSE & other 12th | | |

|7 |examination board candidates) | | |

|8 |Two sets of all the above documents with attestation | | |

|9 |3 passport size & 1 stamp size photographs | | |

| |E stamp 100 rupees 1st Person Student Name 2nd Person SDM College of | | |

|10 |Physiotherapy. Subject- Undertaking. | | |

|11 |Address Proof ( Aadhaar Card copy & Bank pass book copy) | | |

|12 |Anti-Ragging Online Declaration | | |

Office Manager PRINCIPAL REGISTRAR Date:

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