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    Application Form Printout

    Uploaded by

    niku
    This document is an application form for Nikita Subhash Dambale to enroll in the Master of Pharmacy program at Smt. Kishoritai Bhoyer College of Pharmacy. It contains her personal details like name, date of birth, address, contact information, as well as educational qualifications including her Bachelor of Pharmacy degree from Priyadarshani J. L. Chaturvedi College of Pharmacy in August 2015. The application form also lists the specific courses Nikita is applying for in her final year of the Master of Pharmacy program and confirms she has attached the required documents like mark sheets and certificates.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Application Form Printout

    Uploaded by

    niku
    208 views3 pages
    This document is an application form for Nikita Subhash Dambale to enroll in the Master of Pharmacy program at Smt. Kishoritai Bhoyer College of Pharmacy. It contains her personal details like name, date of birth, address, contact information, as well as educational qualifications including her Bachelor of Pharmacy degree from Priyadarshani J. L. Chaturvedi College of Pharmacy in August 2015. The application form also lists the specific courses Nikita is applying for in her final year of the Master of Pharmacy program and confirms she has attached the required documents like mark sheets and certificates.

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    This document is an application form for Nikita Subhash Dambale to enroll in the Master of Pharmacy program at Smt. Kishoritai Bhoyer College of Pharmacy. It contains her personal details like name, date of birth, address, contact information, as well as educational qualifications including her Bachelor of Pharmacy degree from Priyadarshani J. L. Chaturvedi College of Pharmacy in August 2015. The application form also lists the specific courses Nikita is applying for in her final year of the Master of Pharmacy program and confirms she has attached the required documents like mark sheets and certificates.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    208 views3 pages

    Application Form Printout

    Uploaded by

    niku
    This document is an application form for Nikita Subhash Dambale to enroll in the Master of Pharmacy program at Smt. Kishoritai Bhoyer College of Pharmacy. It contains her personal details like name, date of birth, address, contact information, as well as educational qualifications including her Bachelor of Pharmacy degree from Priyadarshani J. L. Chaturvedi College of Pharmacy in August 2015. The application form also lists the specific courses Nikita is applying for in her final year of the Master of Pharmacy program and confirms she has attached the required documents like mark sheets and certificates.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 3

    9/2/2015

    ApplicationformPrintout

    [STUDENTCOPY]
    ApplicationFormNumber:307520

    Smt.KishoritaiBhoyerCollegeofPharmacy
    Kamptee,Kamptee
    RashtrasantTukadojiMaharajNagpurUniversity

    MasterofPharmacy(withCredits)Regular20122013
    Onwards(New)PharmacologyFinalYear
    (MediumEnglish)

    ApplicationForm307520

    1.PersonalInformation
    NameofApplicant:

    NIKITASUBHASHDAMBALE

    Father's/Husband'sName(MiddleName):

    SUBHASH

    DateofBirth:

    16May1991

    Gender:

    PlaceofBirth:

    NAGPUR

    MobileNumbers:8806385050,7798835793

    AddressforCorrespondence:

    MUREMEMORIALHOSPITALCAMPUS,MAHARAJBAGHROAD,SITABULDI,NAGPUR,City:NAGPUR,
    Taluka:NagpurCity,District:Nagpur,State:Maharashtra,Country:India,Pin:440001

    ContactNumber:

    NotAvailable

    Female

    Mother'sFirstname:

    ANITA

    MaritalStatus:

    UnMarried

    EmailId:animary83@yahoo.in

    Reservation/SpecialGroupInformationofApplicant:
    EnrollmentNumber:

    RTMNU/A10/44202

    ExamEvent:

    Mar2015

    SeatNumber:76149

    2.PapersSelectedfor:FinalYear
    MasterofPharmacy(withCredits)Regular20122013Onwards(New)PharmacologyFinalYearSemIII
    3MPH15Seminar(PrestnopsisPresentation)

    3MPHE20D2HerbalCosmetics

    3MPLS13MolecularPharmacologyandToxicology

    MasterofPharmacy(withCredits)Regular20122013Onwards(New)PharmacologyFinalYearSemIV
    4MPL17Dissertation

    4MPL18SeminaronDissertation

    4MPL19VivaVoce

    3.EducationalDetailsSection
    Nameof
    Examination
    SECOND
    SEMESTER
    MASTEROF
    PHARMACY

    NameofBoard/University
    RashtrasantTukadojiMaharaj
    NagpurUniversity

    Dateof
    Passing

    SchoolName
    PRIYADARSHANIJ.L.CHATURVEDI
    COLLEGEOFPHARMACY

    Aug2015

    Grade/Total
    Marks
    SeatNumber
    Obtained
    470/650

    Qualifying
    Exam

    76149

    4.RequiredDocumentsandCertificatesSection(Pleasetickmarkthedocumentthatyouhaveattachedtothisform)
    StatementofMarksofFirstYear/Semester

    StatementofMarksofSecondYear/Semester

    SoM/SoGofQualifyingExamination

    DomicileCertificate.

    5.DeclarationbyApplicant
    Iherebydeclareandagreethat,
    1. ThisApplicationmostlyincludeallthemajorCoursesandCollegesoftheUniversity.However,iftheCoursesandCollegesoftheUniversityarenot
    listedintheapplication,thenitismyresponsibilitytocontacttheCollegeseparatelyforapplyingfortheCoursesthatarenotlisted.
    2. Iknow,UniversitymayaddaffiliationtonewCollegesoraffiliatenewCoursetoexistingCollegesaftermyapplication.Itwillbenotifiedthrougha
    Corrigendumonportal.ItismyresponsibilitytocheckthesameregularlyandapplyforthenewlyaddedCourse/College,ifinterested.
    3. Ihavereadtherulesrelatedtoadmissionandtheinformationfilledinbymeinthisformisaccurateandtruetothebestofmyknowledge.Iwillbe
    responsibleforanydiscrepancy,arisingoutoftheformsignedbymeandunderstandthat,intheabsenceofanydocument,thefinaladmissionwill
    notbegrantedand/oradmissionwillstandcancelled.

    IamawareoftheAntiRaggingActandIstatethatIwillabidebyalltherulesandregulationofthesaidAct.
    Place:
    Date:

    SignatureoftheApplicant:

    6.DeclarationbyParent/Guardian
    Ihavepermittedmyson/daughter/wardtoapplyinyourCollege.Theinformationsuppliedbyhim/heriscorrecttothebestofmyknowledge.Ihave
    acquaintedmyselfwiththerulesandfees/duesrelatedtotheCourse.
    Place:
    Date:SignatureoftheGuardian:
    7.ForCollegeUseOnly
    Designation

    Remarks/Particulars/Recommendations

    SignatureandDate

    AdmissionClerk
    Admission
    Committee
    Accountant/Cashier CashReceived:Rs.

    ReceiptNo.:

    Registrar/Office
    Superintendent
    Note:Afterfillingtheapplicationform,submitthisprintouttotheCollegewiththerequireddocuments.Studentshouldobtainthesignandsealofthe
    College.Otherwiseapplicationwillnotbeconsideredvalidandeligible.

    http://rtmnuadmission.digitaluniversity.ac/OnlineAdmissions/PrintApplication.html

    1/3

    9/2/2015

    ApplicationformPrintout

    x

    x

    http://rtmnuadmission.digitaluniversity.ac/OnlineAdmissions/PrintApplication.html

    2/3

    9/2/2015

    ApplicationformPrintout

    [SUBMISSIONCOPY]

    ApplicationFormNumber:307520

    Smt.KishoritaiBhoyerCollegeofPharmacy
    Kamptee,Kamptee
    RashtrasantTukadojiMaharajNagpurUniversity

    MasterofPharmacy(withCredits)Regular20122013
    Onwards(New)PharmacologyFinalYear
    (MediumEnglish)

    ApplicationForm307520

    1.PersonalInformation
    NameofApplicant:

    NIKITASUBHASHDAMBALE

    Father's/Husband'sName(MiddleName):

    SUBHASH

    DateofBirth:

    16May1991

    Gender:

    PlaceofBirth:

    NAGPUR

    MobileNumbers:8806385050,7798835793

    AddressforCorrespondence:

    MUREMEMORIALHOSPITALCAMPUS,MAHARAJBAGHROAD,SITABULDI,NAGPUR,City:NAGPUR,
    Taluka:NagpurCity,District:Nagpur,State:Maharashtra,Country:India,Pin:440001

    ContactNumber:

    NotAvailable

    Female

    Mother'sFirstname:

    ANITA

    MaritalStatus:

    UnMarried

    EmailId:animary83@yahoo.in

    Reservation/SpecialGroupInformationofApplicant:
    EnrollmentNumber:

    RTMNU/A10/44202

    ExamEvent:

    Mar2015

    SeatNumber:76149

    2.PapersSelectedfor:FinalYear
    MasterofPharmacy(withCredits)Regular20122013Onwards(New)PharmacologyFinalYearSemIII
    3MPH15Seminar(PrestnopsisPresentation)

    3MPHE20D2HerbalCosmetics

    3MPLS13MolecularPharmacologyandToxicology

    MasterofPharmacy(withCredits)Regular20122013Onwards(New)PharmacologyFinalYearSemIV
    4MPL17Dissertation

    4MPL18SeminaronDissertation

    4MPL19VivaVoce

    3.EducationalDetailsSection
    Nameof
    Examination
    SECOND
    SEMESTER
    MASTEROF
    PHARMACY

    NameofBoard/University
    RashtrasantTukadojiMaharaj
    NagpurUniversity

    Dateof
    Passing

    SchoolName
    PRIYADARSHANIJ.L.CHATURVEDI
    COLLEGEOFPHARMACY

    Aug2015

    Grade/Total
    Marks
    SeatNumber
    Obtained
    470/650

    Qualifying
    Exam

    76149

    4.RequiredDocumentsandCertificatesSection(Pleasetickmarkthedocumentthatyouhaveattachedtothisform)
    StatementofMarksofFirstYear/Semester

    StatementofMarksofSecondYear/Semester

    SoM/SoGofQualifyingExamination

    DomicileCertificate.

    5.DeclarationbyApplicant
    Iherebydeclareandagreethat,
    1. ThisApplicationmostlyincludeallthemajorCoursesandCollegesoftheUniversity.However,iftheCoursesandCollegesoftheUniversityarenot
    listedintheapplication,thenitismyresponsibilitytocontacttheCollegeseparatelyforapplyingfortheCoursesthatarenotlisted.
    2. Iknow,UniversitymayaddaffiliationtonewCollegesoraffiliatenewCoursetoexistingCollegesaftermyapplication.Itwillbenotifiedthrougha
    Corrigendumonportal.ItismyresponsibilitytocheckthesameregularlyandapplyforthenewlyaddedCourse/College,ifinterested.
    3. Ihavereadtherulesrelatedtoadmissionandtheinformationfilledinbymeinthisformisaccurateandtruetothebestofmyknowledge.Iwillbe
    responsibleforanydiscrepancy,arisingoutoftheformsignedbymeandunderstandthat,intheabsenceofanydocument,thefinaladmissionwill
    notbegrantedand/oradmissionwillstandcancelled.

    IamawareoftheAntiRaggingActandIstatethatIwillabidebyalltherulesandregulationofthesaidAct.
    Place:
    Date:

    SignatureoftheApplicant:

    6.DeclarationbyParent/Guardian
    Ihavepermittedmyson/daughter/wardtoapplyinyourCollege.Theinformationsuppliedbyhim/heriscorrecttothebestofmyknowledge.Ihave
    acquaintedmyselfwiththerulesandfees/duesrelatedtotheCourse.
    Place:
    Date:SignatureoftheGuardian:
    7.ForCollegeUseOnly
    Designation

    Remarks/Particulars/Recommendations

    SignatureandDate

    AdmissionClerk
    Admission
    Committee
    Accountant/Cashier CashReceived:Rs.

    ReceiptNo.:

    Registrar/Office
    Superintendent

    http://rtmnuadmission.digitaluniversity.ac/OnlineAdmissions/PrintApplication.html

    3/3

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