ADMISSION FORM
BDS PROGRAM 2017-18
absmids
A B SHETTY MEMORIAL INSTITUTE OF DENTAL SCIENCES
(A constituent unit of Nitte University)

Please complete all sections of the form.Read the guidance notes before completing the form
Category:
NEET ROLL NO All India NEET Rank NEET Score

A. PERSONAL DATA
*Name (As per the class X certificate) Please upload your photograph
Gender Male   Female   Transgender
*Date of Birth (dd/mm/yyyy)
Nationality Mother Tongue
Country of Permanent Residence State of Domicile
Do you belong to SC   ST   OBC   Category1 Any other caste (specify)
Blood group
Father's Name Occupation
Annual income
Mother's Name Occupation
Annual income

B. CONTACT DEATILS
Current address for correspondence click here
to copy the address
Permanent Address
Pin code Pin code
District District
State State
Country Country
Tel No.(with code) Tel No.(with code)
Father's Mobile Number Mother's Mobile Number
Student's Mobile Number Local Guardian's Mobile Number
Father's/ Mother's E-Mail ID *Student's E-Mail ID
PAN Number( Father ) PAN Number( Mother )
Aadhaar Card Number of the student
Place of residenceUrban   Rural
Hostel RequiredYes   No

C. ACADEMIC QUALIFICATION
Qualifying Exam PassedCollegeBoard/UniversityRegister NumberMarksOverall Percentage(%)
MaxObtained

MARKS OBTAINED IN THE QUALIFYING EXAMINATION
SubjectMarksPercentage(%)
MaximumObtained
Physics
Chemistry
Biology
Total
English

D. DECLARATION BY THE STUDENT

I have carefully read the details regarding admission to BDS course. I declare that the information provided by me in this application is true and correct to the best of my knowledge. Should it be found that the information furnished is untrue in material particulars, I know that I am liable for criminal prosecution and will forego the allotted seat. In all matters regarding my admission to the course, the decision of the College is final and binding. I am also aware that the college will not refund the fees either in full or in part, under any circumstance. If I intend to discontinue the course at any time after joining, I hereby undertake to pay the college fees and dues as applicable for the remaining years of the course. I am aware that any dispute arising out of the admission to the course will be subject to the jurisdiction of the courts of the city of Mangalore or the Honorable High Court of Karnataka.


Place Agree to the condition
Date25-09-2017

E. DECLARATION BY THE PARENT / GUARDIAN
(to be signed by the guardian only if both parents of the applicant are not alive)

I,* hereby affirm that the information provided and enclosures submitted thereto in this application of my son / daughter / ward * for admission to the BDS course is true and correct to the best of my knowledge. Should it be found that the information furnished is untrue in material particulars, I know that I am liable for criminal prosecution and he / she will forego the allotted seat. I am aware that in all matters regarding his / her admission to the course, the decision of the College is final and binding.I am also aware that the College will not refund the fee either in full or in part, under any circumstance.If my ward decides to discontinue the course at any time after joining, I hereby undertake to pay the college fees and dues for the remaining duration of the course. I am aware that any dispute arising out of the admission to the course will be subject to the jurisdiction of the courts of the city of Mangalore or the Honorable High Court of Karnataka.


Place Agree to the condition
Date25-09-2017

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