Untitled Document

 

Application for Admission

Note: Please read the instructions and form carefully before filling it. Mandatory fields are marked with '*' next to the title. Please write N/A if a particular field is not applicable.

Type of Admission:*
Academic Year
 
Mode of Admission:*
Session:*
Center Code:* 
 
   

Upload Image*

Programme Applied For:*
Specialization:*
Select Term:*

(for programme list see ortibanda.in)
 

Personal Information

Name :* 

(based on the certificate of 10th examination)

Date of Birth:* 
Age:* 
Gender (M/F):*  Category:* 
Nationality:* 
If others please specify: 
Marital Status:* 
Proof of Residence:*  Email:* 

Please enter your personal email id. Center email ids will not be accepted.


Correspondence Address:

  • Address Line 1 :* 
  • Address Line 2 : 
  • City :* 
  • State :* 
  • Pin(Zip) Code:* 
  • Phone No :* 
  • Mobile No :* 

Check this box to copy same address below. 

Permanent Address

  • Address Line 1 :* 
  • Address Line 2 : 
  • City :* 
  • State :* 
  • Pin(Zip) Code:* 
  • Phone No :* 
  • Mobile No :* 

Check this box to copy correspondence address below. 

Contact Details of Guardian

  • Guardian Name:* 
  • Address Line 1 :* 
  • Address Line 2 : 
  • City :* 
  • State :* 
  • Pin(Zip) Code:* 
  • Phone/Mobile No :* 

Family Details

  Name Occupation Phone No Mobile No E-Mail Address
Father*
Mother*

Academic Information

Name of Qualifying Examination* Month & Year* Percentage*

Educational Qualification

Examination Stream

For example B.Sc maths/B.Tech/B.A/BRT

Name of the
School / College and
Board / University
Year of
passing
Subject Studied Marks Obtained Maximum Marks Percentage
10th*
12th
Graduation
Post Graduation
Other Educational
Qualifications

  • Awards and Achievements (if any) : 
  • Participation in Extracurricular Activities : 

Employment History

Work experience :
If yes then Total Experience
Years:  Months:  


Payment Mode:* Bank Name:* DD Number:*      Amount* DD Date:*
Rs 

Declaration

I hereby certify and declare that the information given in the Application is complete and accurate to the best of my knowledge.
I understand and agree that misrepresentation or omission of facts will justify the denial of admission/cancellation/expulsion. 
I abide to all the terms & conditions of the University 

 

 

 

.

Contact Us



Name :
Mobile :
Email :
   

Get Connected

HOME | ABOUT US | PROGRAMMES | ADMISSIONS | ACCREDITATION | GALLERY | FACILITIES | BOARD | CONTACT US
Copyright 2016-All Rights Reserved by
SHRI RAJARAM MEMORIAL EYE HOSPITAL SOCIETY

Visitor Counter
logo design dubai