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M.S. RAMAIAH COLLEGE OF PHARMACY

M.S.R. NAGAR, M.S.R.I.T. POST, BANGALORE – 560 054.
APPLICATION FORM FOR M.PHARM COURSE 2011-2012
(P’COGNOSY / P’CHEMISTRY/P’CEUTICS)
(UNDER MANAGEMENT QUOTA) BLOOD GROUP

01 Name of the applicant

(Male / Female)
A. Name of the father, educational
qualification & occupation.
02 B. Name of the mother, educational
qualification & occupation
C. Mother Tongue
03 Date of birth & age of the candidate

Complete address for communication

04
(With Pin code)

Contact Phone No. with STD code:

05
Mobile Phone No:
06 Nationality Indian / NRI / Foreign
Name of the college where the student studied
07
B.Pharm
08 Name of the University

09 Passing Year B.Pharm

Attested copy of Marks Card enclosed
10 Yes / No
10th, +2 or P.U.C & 4year B.Pharm Course
Year % of Class obtained No. of
Marks Attempts
I

Percentage obtained in 4 year B.Pharm Course II

11
& Class III

IV
Overall Percentage
12 State Pharmacy Council registration details
Degree Certificate Details a) Convocation held on :
13
(Enclose Xerox copy of the Degree certificate) b) Certificate No. :
M.Pharm course applied for
14 (Pharmacognosy / Pharmachemistry)

1
 General Category / *OBC / *SC / *ST
15 Caste details (Please tick √ )
(*Enclose caste certificate copy)

Common Entrance Exam details if any,

16
CET Rank / Similar Entrance exam details

17 GATE Score and Rank

D.D. Details for Rs.750/- drawn in favour of
18 “M.S. Ramaiah College of Pharmacy, payable at
Bangalore”
19 Whether you want hostel accommodation Yes / No

Signature of the Student Signature of the parent / guardian

Date:
Place:

FOR OFFICE USE ONLY

Sl. No. of the Application

01
& Date received

02 D.D Details

03 Rank as per the Merit List / Test

04 Selected / Not selected
05 Fees paid Details

06 Remarks if any,

Date: (Signature of the Principal

Chairman Selection Committee)
2