Application Number: 2087118

PROGRAMS

Course Groups - [Courses] Group ID-1 - [MBBS]

Test Centers Hyderabad,Gulbarga

BASIC INFORMATION

First Name Mohammed Email ID momudassirj@hotmail.

com

Last name Jaweed Mobile Number 9849021532

Parent's Name Jaweed Jeelani Phone Number 23533696

Gender Male Address 10-3-282/2/

A/18, Humayun
Nagar,Hyderabad
Plot no.177,Road
no.11,Banjara Hills,Hyd
Nationality Indian

Student Photo Student Signature

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EDUCATION QUALIFICATION

University Name Sri Chaitanya Junior Qualifying Exam Intermediate

College

Board/University Board of Intermediate Year of Passing 2014

Education

PAYMENT DETAILS

Payment Type ONLINE(CCAvenue) Payment Amount 1600

OTHER INFORMATION

Date of Completion of Are you a diploma

Internship holder?

Exam Name Exam Score

Registration No: Completion Year

I confirm that I fulfil the eligibility criteria for the course I am applying for.

I understand that no refund will be made on the application fee if I am not eligible for the programmes I am applying for.

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DECLARATIONS
I hereby declare that all the particulars stated in this application form are true to the best of
my knowledge and belief. I have read and understood all provisions of admissions and agree
to abide by them. I also affirm that I fulfil the eligibility requirements for the course/s applied.
In the event of submission of fraudulent, incorrect or untrue information or suppression or
distortion of any fact, like educational qualification, marks, nationality etc. I understand that my
admission/degree is liable for cancellation. I further understand that my admission is purely
provisional subject to the verification of the eligibility conditions. NOTE: 1. Please keep a copy
of the filled in application for future reference. 2. Application number must be quoted in all future
correspondence. 3. Please mail the printed copy of the completed application form along with
the DD/Challan (if payment is not via Credit / Debit Card) to: The Director, Admissions, Manipal
University, Manipal - 576104

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