8/13/2019 mdmsmch.aiimsexams.org/RegistrationSlip?

id=F+IBPDpj+zRN/aFXBZvaHA==

All India Institute of Medical Sciences

Ansari Nagar, New Delhi - 110608

Basic Registration Form - AIIMS PG Courses[MD/MS/MCh(6YRS)/DM(6YRS)/MDS]

Candidate Profile Registration ID: P6141269270 Registration Date: 13/08/2019

Candidate Name: SHIVANI KATAL

Date of Birth: 29 Jan 1996 Category: SC

Gender: Female Marital Status: Unmarried

Father's Name: RANDHIR SINGH Mother's Name: KUSHAL BINDU

PWBD Status: No PWBD Category: NA

Nationality: INDIAN

Identification Mark(1): mole on left side on nose Identification Mark(2):

mole on neck anteriorly

Contact Details

Address for Permanent: Correspondence Address:

H NO. 372 VISHAWKARMA CHOWK, ASHRAM STREET DIGIANA, H NO. 372 VISHAWKARMA CHOWK, ASHRAM STREET DIGIANA,
PO GANGYAL JAMMU, Gangyal , Jammu, JAMMU & KASHMIR, PO GANGYAL JAMMU, Gangyal , Jammu, JAMMU & KASHMIR, India,
India, 180010 180010

Mobile No: 1. 9469552054 , 2. Alternate-MobileNo 9419120052 E-Mail ID: katal96.js@gmail.com

Valid Photo Identity (To be presented in original at the Examination Center along with Admit Card)

ID Proof: PAN Card ID No: DMCPK9498B Place of Issue: India Issue Date: NA Valid Till: NA

UNDERTAKING/DECLARATION: I hereby declare that the information furnished by me in the Registration/Application Form is correct and nothing has been
concealed. In case any information furnished by me is found to be false/incorrect/untrue than i shall be liable to civil/criminal prosecution and my claim to
admission/appointment/registration/ service in the Institute may be cancelled/terminated.

Signature of Candidate
Thumb of Candidate

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