Christian Medical College, Vellore - 632002. Medical PG Application - 2012 Provisional registration No.

APPLICATION No.

39914

1230086

1. Name of the Candidate (as in University records)

A D I T Y A
Father's Name:

J O H N

B I N U

V.J. BINU

2. Addresss for Communication (Do not enter your Name here)

VALETH, KP/16/89, UNRA-32,N.C.C. ROAD PERURKADA P.O. THIRUVANANTHAPURAM KERALA

6 9 5 0 0 5
PHONE : (STD Code - Number)

0 4 7 1 - 2 4 3 4 0 8 4 9 5 6 7 5 8 9 8 2 7
adityabinu@gmail.com

MOBILE :

email : 3.Sex (M/F)

4.Date of birth (DD MM YYYY)

5.Religion*

6.Community*

7.State of Domicile*

M
8. Medical College for MBBS *

0 5 0 5 1 9 8 5
9. Medical College/Hospital for Internship *

0 1

0 5
10. Date of (expected) Completion of Internship

1 6
11. Best outgoing student ? Y/N (enclose certification, Annexure-4)

0 1
12. Details of Academic Training Course Subject INTERN

0 1

3 1 1 0 2 0 0 9
Expected / Date of COMPLETION OF COURSE SPONSOR CODE # (IF APPLICABLE)

N
Expected / DATE OF COMPLETION OF SPONSORSHIP OBLIGATION

MBBS DIPLOMA DEGREE/DNB

3 1 1 0 2 0 0 9

1 7

1 1 1 1 2 0 1 1

13. Details of work in an area of need after Internship and sponsorship obilgation. If yes, Indicate Months of Service and

enclose certification - Annexure 5

14. Work experience at CMC, Vellore if any:(USE separate sheet if necessary) Designation Emp No Appointing authority INTERN

2 4
Months of service

Date of appointment

15. CENTRE FOR ENTRANCE TEST*

29070

0 1

0 1 1 1 2 0 0 8

1 2

0 8

16. Course(s) applied for IN ORDER OF PREFERENCE

(# if applying for sponsorship from more than one agency indicate in second column. see Annexure 2 for code)

17.Payment Details:
(Rs. 750 for application)
Sponsor Code 2(#)

Preference 1 Preference 2 Preference 3 Preference 4 Preference

Course Code(#)

Entrance Exam Code *

Sponsorship applied for Y/N

Sponsor Code 1(#)

Rs.2550/-

J 1 V 1 V 3

P Z P Z P Z

N N N N Y

Note: Rs. 600 per preference to be enclosed (max 4 courses in 2 subjects ONLY) 18. Will you have fulfilled ALL THE ELIGIBILITY REQUIREMENTS INCLUDING COMPLETION OF SPONSORSHIP OBLIGATION as detailed in the bulletin, within the time of admission for the course(s) applied to above (Y/N) (If No, give details separately)

THE COMPLETED FORM WITH ALL ENCLOSURES MUST REACH THE REGISTRAR, CMC, VELLORE 632002 BY 29th October 2011

ADITYA JOHN BINU

ADITYA JOHN BINU

1230086 Rs.2550/-

1230086 Rs.2550/-

OFFICE OF THE REGISTRAR CHRISTIAN MEDICAL COLLEGE VELLORE 632 002

Dear Mr / Ms. ADITYA JOHN BINU

Your application number

Your provisional Reg. No. is

1230086

39914

Use the application number as ID and registration number as password to download your hall ticket after 15th November 2011 from our website http://home.cmcvellore.ac.in/admissions/admin.htm Please note that your registration is provisional and will be authenticated only after the printed application form with relevant enclosures are received at our office Please keep this safely for your reference.

REGISTRAR