MDS 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

Migration Certificate No*

Date*

Whether worked as College Faculty*

BDS passing College*

Educational qualification BDS

Board/University*

Month & Year of passing*

KDC Regn*

Total Marks*

Percentage*

Whether attended BLS*

BLS No*

Valid till*

Internship completion details

College*

Starting Date*

Ending Date*

NEET PG details

Name of examination*

Authority*

Reg. No*

Roll No*

Rank No*

All India (overall)*

Category*

Category of PH Rank*

Percentile Score*

Total Marks*

All India Quota*

KEAM Details

Year*

Roll No*

Rank*

Date of allotment Memo*

Category(Gen, SC, ST, OBC, OEC, Ez, MU, BH 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.