VADAMALAYAN

INSTITUTE OF MEDICAL AND

ALLIED HEALTH SCIENCES
Affiliated with THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY
(Institution Code : 444)
#15, Jawahar Road, Chokkikulam, Madurai(625002),Tamil Nadu, India.
Phone : 0452- 2545491, 7708259595.
Email ID: paramedical@vadamalayan.org; Website: www.vadamalayan.org

INSTRUCTIONS
1. The requested details are to be filled in BLOCK LETTERS and in the candidate’s own
handwriting neatly and legibly. Affix your
2. Please enclose photo copies of mark sheets & certificates along with this form. latest
3. All Original Certificates should be produce only at the time of admission. passport
size
Courses Offered photograph
here
Code No. Course Name
8001 B.Sc. Accident and Emergency Care Technology Kindly mention any one course code number in
the option
8002 B.Sc. Operation Theatre and Anesthesia Technology
8005 B.Sc. Dialysis Technology
Option :
8006 B.Sc. Cardiac Technology
8008 B.Sc. Physician Assistant
Note : The option you have selected would be given the first preference.
8013 B.Sc. Nuclear Medicine Technology
8023 B.Sc. Radiography and Imaging Technology

Personal Data:

1.Name (As per your certificate)

2. Date of Birth : 3. Sex / Gender 3.1 Marital Status

D D M M Y Y Y Y M F Single Married

(The candidate should have completed 17 Years of age at the time of admission or should complete the age on or before 31st De cember of the year
of admission)

4. Nationality : 5.Religion : 6. Blood Group:

7. Community: Community Certificate No.

8. Father Name :

Father Profession : Annual Income Rs.

9. Mother Name

Mother Profession : Annual Income Rs.

10. Present Address with Pin Code Permanent Address with Pin Code

11. Mobile No.: 12. Landline No.:

13. Email Id (Candidate) :

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 14. Qualification Details (with reference of HSC Certificates)
Exam Passed Board School Place State District

Duration Registration No Month & Year of T.C. No T.C.Date School Relieving Date
Passing

14.1.
Subject Tamil English Physics Chemistry Botany Zoology Biology Maths Comp. Sci. Vocational Percentage

Marks
obtained

Total

14.2. Did you reappear for HSC? Yes No If “Yes” Give Details

1st 2nd 3rd

Month & Year of Reappearance

Registration No.

15. Personal identification marks

a._______________________________________________________________________________________________

b._______________________________________________________________________________________________

DECLARATION:
All entries made in the application form are true to the best of my knowledge and belief. I am willing to produce original
certificates on demand at any time. I also undertake that I shall abide by the rules and regulations of Vadamalayan Institute of Medical
& Allied Health Sciences and The Tamil Nadu Dr.M.G.R.Medical University.

Place :
Date :
Signature of the Applicant

UNDERTAKING:
I ..................................................................father/mother/guardian of...................................................................do here by
accept responsibility for good conduct of my son/daughter/ward during the entire period of the course, both inside and outside the
campus.

Place :

Date : Signature of Parent/Guardian

Note: Kindly enclose the following certificate photo copy along with filled application.

1) SSLC, HSC I year and HSC II year mark sheet 3) Community Certificate
2) Transfer Certificate 4) Aadhar Card

Application fee payment Details : 1) Demand Draft / NEFT Transaction details

DD No. / NEFT Reference No

Date
Reference Name
Name of the Bank

FOR OFFICE USE ONLY

Date of interview

SELECTED NOT SELECTED

Candidate has been offered admission in ________________________________________________Course of he batch

____________________________ commencing on _________________________________.

Signature of the Principal with Seal

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