Admission Form

APPICANT DETAILS (2021-22)

Enquiry for MBBSDMLTDMLT (Tech)DOTTDCCTDIALYSIS (Tech)DRD (Tech)D. OPTDCLTECG (Tech)

First Name*

Middle Name

Last Name*

Date Of Birth*

Gender* MaleFemale

Marital Status* SingleMarried

Mothers Name*

Mothers Occupation*

Fathers Name*

Fathers Occupation*

Parent's Phone*

Parent's Email*

Guardian's Name*

Guardian's Occupation*

Permanent Address*

City*

State*

PIN Code*

Correspondence Address*

City*

State*

PIN Code*

Phone*

Mobile*

Email*

Category* GENSCSTOBC

Nationality*

Blood Group*

Mother Tongue*

Languages Known*

Hostel Facility Required* YesNo

Details of H.S. or Equivalent Examination

Name of Board/Council*

Month & Year of Passing of the Qualifying Examination

Month of Passing

Year of Passing

SUBJECT	Physics	Chemistry	Biology	Total	English
Full Marks
Marks Obtained
(%)

DETAILS OF NEET EXAMINATION

NEET ROLL NO.
ALL INDIA RANK
NEET CATEGORY

OVERALL RANK
CATEGORY RANK
STATE RANK

NEET MARKS OBTAINED
TOTAL MARKS
PERCENTILE SCORE

a.Photo identity proof in the form of class X Admit Card/ Certificate with attested photo from Head of Institution last studied/ Copy of : Passport/ Aadhaar Card/ PAN Card/ Driving License
b. Copy of marksheet of Class XII or equivalent examination self attested
c. Copy of Birth Certificate for proof of age (if date of birth not given in the HSC marksheet/certificate).
d. NEET Score Card.

Applicant’s Declaration

I wish to apply for admission to the Gouri Devi Institute of Medical Sciences & Hospital MBBS course and declare that all the above particulars are true to the best of my knowledge and belief. I agree that acceptance of this application does not confer on me any right in respect of selection for admission. I have not taken admission in any institute after passing the H.S. or equivalent examination.

I agree to pay the College Semester Fees as determined by the Fees Fixation Committee, Govt. of West Bengal.

Date

Photograph

Parent's/Guardian’s Declaration:

I am aware of the financial obligations in my ward's applying to Gouri Devi Institute of Medical Sciences & Hospital, Durgapur and I undertake to pay the tuition and other fees payable to the Institution as per the rules of the Institution. I also affirm that my ward shall follow all the rules and regulations as prescribed by the College from time to time.

Date

Are you Human? 66+10?

Anti Ragging Toll FREE Number: 18008900779

APPICANT DETAILS (2021-22)

Applicant’s Declaration

Parent's/Guardian’s Declaration: