(Approved by AICTE , PCI New Delhi & Affiliated to JNTU, Kakinada)

Estd:2006
ISO 9001:2015, ISO 14001:2015, OHSAS 18001:2007 Certified Institution

Beside VSEZ, Duvvada, Visakhapatnam – 49. Email: viptvizag@gmail.com, Website:www.vignanpharma.com

0891- 2511222 , 2589777, Fax : 0891 - 2752333

Application for admission to B.Pharmacy & Pharma.D Programme under Management Quota (Category –B) for the academic year2018-19

Entrance examination details:

Name of Entrance Exam EAMCET 2018 Photograph
State Rank

Rank

H.T.No.

Academic details of the student:

Class Name of the Institution Yearof % of

Pass marks

X Class

Intermediate/
CBSE + 2

Personal details of the student:

1. Name of the student :
(as per SSC)

2. Sex (M / F) :

3. Date of Birth (as per SSC) :

4. Name of the parent / Guardian :

5. Name of the Mother :

6. Address for Communication :

S/o. D/o. C/o :

H.No. / Street :

Village / Town :

Mandal / District :

State :

Cell Phone No. :

E-mail ID :

7. Any other relevant information :

Indicate category by selecting the appropriate box

OC BC-A BC-B BC-C BC-D BC-E SC ST

Student’s Undertaking : I undertake to state that all the information furnished by me is true to the best of my
knowledge. I acknowledge that any misrepresentation of information might lead to the disqualification of my
admission. I shall abide by the rules and regulations of the college and also undertake not to indulge in any activity,
which is restricted by the college.

Signature of the student

Parent’s Undertaking : I shall undertake the responsibility of good conduct and behavior of my ward during his /
her stay at the college and shall pay tuition and other fee as and when demanded by the college. I also understand
that as per university guidelines, a minimum attendance of 75% is essential for my ward to be allowed to write the
university examinations.

Signature of the Parent

FOR OFFICE USE ONLY

Date of application : Branch :

Website: vignanpharma.com
Contact us : 0891-2511222, 2589777, 9866399928 - Fax : 0891-2752333