Application form for

Master of Pharmacy (M Pharm) / PHARM. D. (Post Baccalaureate)

First Name:

Father's/Husband's Name:

Mother's Name:

Surname:

Date of Birth:

Nationality Status:

Sex:

Photo:

Signature of the candidate :

Domacile:

Mobile No.:

Admission preferrence 1

Admission preferrence 2

Address:

Name of the College from which the candidate has passed & address:

District:

State:

Name and address of parent:

Parent Address:

Declaration:

1.I hereby declare that the above information is true and complete to the best of myknowledge. I am aware that if any information herein is found to be incorrect or incomplete, myapplication form will be rejected/ admission will be cancelled.

2.If admitted to this Institution I shall abide by its rules and regulations.

3.I have read and understood all the provisions contained in the brochure and hereby agree to abide by these provisions.