Student's Name
        Father's name
        Mother's name
        Mobile No.

Date Of Birth
                   Gender
MaleFemaleOther         PAN Number(Self)
        E-mail Address
        Address
       
State         City
        Pincode
                                High School Qualification

Intermediate Qualification
          Addhar Number
                Select Course
B.PharmaD.PharmaGNMANMITI (F)ITI (E)B.EDB.AB.ComB.Sc NursingM.Pharma                                  Student's Photo

Student's Signature
        Aadhar Document Image
        High School & Inter Marksheet
        Hostel Required
Yes, Hostel is RequiredNo, Hostel not Required

Weather applied for UPSEE / JEECUP applicable only for B.Pharma / D.PharmaYESNO