BDS Admission Form

(Applicable for CEE allotted candidates only)

Fill up all details in block letters Application which is not complete in all respects is likely to be rejected

Applicant Details

Name of the Applicant*(AS PER CLASS 10th Certificate)

Expansion of Initials

Date of Birth*

Age*

Gender*

Recent Passport Size Photograph*

Blood Group*

Mobile No*

WhatsApp Number*

E-mail ID*

Aadhar No*

Nationality*

Citizenship*

Religion*

Caste*

Category*

Mother Tongue*

Parent / Guardian Details

Father's Name*

Educational Qualification*

Occupation

Mobile Number*

E-mail*

Mother's Name*

Mobile*

E-mail*

Local Guardian (if applicable)

Students whose place of residence is outside Ernakulam must provide the details of a Local Guardian. Students residing in Ernakulam may enter “NIL”.

Name*

Mobile Number*

Address Details

Communication Address

House Name*

Street/Place*

Post*

District*

State*

PIN*

Country*

Same as Communication Address If different, provide address.* YesNo

Hostel & Other Information

Whether Hostel facility required*

If No, place of stay*

Hostel Name (if outside college hostel)*

Warden Contact Number*

Licence Number (if applicable)*

belongs to BPL? If yes, Supporting document

YesNo

Educational Details

Name of the school last attended and year of study*

Migration Certificate No*

Date of Issue*

Eligibility Certificate (Open University Candidates Only)

If yes, Supporting document

YesNo

Plus Two / Qualifying Examination

Board/University*

Month & Year of passing*

Subjects*

Max. Marks*

Marks Obtained*

Percentage*

Physics*

Chemistry*

Biology*

English*

Maths*

Total PCB Marks*

Total Marks*

Entrance Examination Details

NEET Details

Examination Authority*

Application Number*

Roll No*

Rank*

Percentile*

Score*

Total Marks*

All India Rank*

Category Rank*

KEAM Details

Year*

Roll No*

Rank*

Date of allotment*

Category(SM,SC,ST,OBC,OEC,EZ,MU,BH,NRI ETC)*

I hereby agree that the foregoing information is correct and complete to the best of my knowledge and belief, nothing has been concealed / destroyed.