| Application For Course : |
Medical: |
| Exam Center First Choice |
| Dehradun: |
Haridwar: |
Vikasnagar: |
Kotdwar: |
Srinagar: |
Roorkee: |
Uttarkashi: |
| Exam Center Second Choice |
| Dehradun: |
Haridwar: |
Vikasnagar: |
Kotdwar: |
Srinagar: |
Roorkee: |
Uttarkashi: |
| 1. NAME IN FULL : |
| 2. FATHER'S /GUARDIAN'S NAME: |
3. MOTHER'S NAME : |
| 4.PARENT'S / GUARDIAN'S OCCUPATION : |
5. ANNUAL INCOME : |
| 6. DATE OF BIRTH : |
7. GENDER : |
| 8. CATEGORY : |
9. SUB CATEGORY: |
| 10. PERMANENT ADDRESS (do not write father's / gardian's name here) : |
| 11. CITY : |
12. PIN NO : |
| 13. PHONE NO : |
14. MOBILE NO : |
| 15. E-MAIL : |
| 16. NAME OF THE SCHOOL (from where appeared / appearing for class X / XI / XII) : |
| 17. PERCENTAGE OF MARKS OBTAINED IN CLASS X : |
| Maths : 0.00 % |
Science : 0.00 % |
Aggregate : 0.00 % |
| 18.PERCENTAGE OF MARKS OBTAINED IN CLASS XII : |
| Physics : 0.00 % |
Chemistry : 0.00 % |
Maths : 0.00 % |
Biology : 0.00 % |
Aggregate : 0.00 % |
| Amount : |
Mode Of Payment : |
DD No.: |
Name Of Deposit Bank : |
Deposit Date : |
NOTE:
The 100% scholarship will be provided to 50 successful and eligible candidates, after taking admission in Baluni Classes.
Entrance Examination Fees:- Rs. 500/- (for All Candidates). If you pay Exam Fee by Demand Draft mode, Please make Demand Draft in favour of "Baluni Classes" payable at Dehradun & Send completely filled form with Original Demand Draft to Baluni Classes, C-7, Nehru Colony, Near Main L.I.C. Building, Haridwar Road, Dehradun (Pin-248001) via Speed Post.
DECLARATION :
I hereby declare that all the information furnished by me are correct and true to the best of my knowledge and belief and nothing has been concealed. In the event of any information found incorrect or misleading, my candidature shall be liable to cancellation by Baluni Classes at any time.
Signature of Candidate :
|
Signature of Parent/Guardian :
|
Date : |
| Place : |
