KERALA STATE SELF FINANCING PHARMACY COLLEGE MANAGEMENT ASSOCIATION

APPLICATION FOR ADMISSION TO B. PHARM / PHARM . D/ D. PHARM 2019-2020

All fields marked with asterisk (*) must be completed

Course applied for
(Each application shall be used for only one course)*
B. PHARM   D. PHARM

 

 

College Applied*

 

Name in Block Letters *

 

Sex*
Male   Female

 

Date of Birth (DD/MM/YYYY) *

 

Age *

 

Name of Father *

 

Name of Mother *

 

Religion *

 

Community *

 

Permanent Address*

 

Address for Communication

 

Phone No

 

Mobile No*

 

Mail Id*

 

Qualifying Examination *

 

University / Board *

 

Register Number, Passing Year, Passing Month *

 

Upload Photo

 

 

Marks Secured in HSE/ VHSE/ Examination

Subjects Maximum Marks Marks Secured Percentage No. of Chances
Physics
Chemistry
Biology
Mathematics
Computer Science
Biotechnology
Total Marks

Annual Income of the Family:

 

If the candidate is claming any reservation or other benefits, furnish details *

 

 

Application Fee Details

DD No Date Bank Amount

Declaration*

I do hereby declare that the particulars given in the application are true to the best of my knowledge and belief. If any of the particulars given by me in this application is proved fraudulent at any later stage of admission, I shall be liable for disciplinary action and my admission shall become null and void. I shall produce the originals of the certificates at the time of interview. I carefully read the prospectus thoroughly and I am ready to abide the terms and conditions mentioned in the Prospectus.

 

Place:
Date: 15/11/2019
Name & Signature of the Candidate:
Name & Signature of Parent or Guardian

 

Declaration *

I do hereby declare that the particulars given in the prospectus are carefully read and understood. I carefully read the prospectus thoroughly and I am ready to abide the terms and conditions mentioned in the Prospectus.

 

Place:
Date:15/11/2019
Name & Signature of the Candidate:
Name & Signature of Parent or Guardian

 

Notes: *

  • Duly filled application form along with relevant documents and DD for Rs. 1000/- in favour of ‘Hindustan College of Pharmacy’ Payable at Kanjirappally, should be submitted to the office of the college on or before 28-10-2019
  • Applications received after the prescribed date will not be entertained under anycircumstances.
  • Application forms not supported by relevant documents will not beconsidered.
  • Attach Copy of 10th Standard & 12th Standard.
  • A self addressedenvelop (25 x 12 cm size) with India Postal Stamp sufficient for sending the selection memo by registered post shall also be attached.