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(IOMIT's)

SIR SEEWOOSAGUR RAMGOOLAM MEDICAL COLLEGE
BELLE RIVE, MAURITIUS
APPLICATION FORM FOR MBBS COURSE 2017-2018    000510/15202

SIGN OF ISSUING AUTHORITY
1. ROLL NUMBER :-
(NOT TO BE FILLED BY CANDIDATE)
UPLOAD PHOTO :-

2. NAME OF THE APPLICANT :-
3. FATHER'S/GUARDIAN'S NAME :-
4. FATHER'S OCCUPATION :-
5. MOTHER'S OCCUPATION :-
6. ADDRESS FOR CORRESPONDENCE :-
STATE :- PIN :-
PHONE:- FAX :-
7. EMAIL:-
8. NATIONALITY:-
9. PASSPORT NO:-
EXPIRY DATE :-
10. DATE OF BIRTH:-
11.CENTER OF PREFERENCE:-
12.COURSE:-
13.TOTAL MARKS AT 10TH /O LEVEL EXAMINATION
OBTAINED MARKS TOTAL MARKS
14.SUBJECT WISE MARKS/GRADE IN THE CLASS 12TH /A LEVEL EXAMINATION
OBTAINED MARKS/GRADE   TOTAL MARKS
BIOLOGY :-      
PHYSICS :-      
MATHS :-      
CHEMISTRY :-      
ENGLISH :-      
15. DETAILS OF THE QUALIFYING EXAMINATIONS CLASS 12TH/A LEVEL MATRICULATION OR EQUIVALENT:
EXAMINATION SCHOOL /COLLEGE UNIVERSITY /BOARD YEAR OF PASSING & ATTEMPT COUNTRY
XTH/O LEVEL
XIITH/A LEVEL
16. LANGUAGES KNOWN:    ENGLISH FRENCH HINDI OTHER
I7. WHETHER HOSTEL IS REQUIRED:  
DECLARATION

1. I wish to apply for admission to the IOMIT's SSR Medical College, Mauritius and hereby declare that the above information is true and complete to the best of my knowledge. I am aware that if any information herein is found to be incorrect or in complete, my application will be rejected & admission will be cancelled.

2. lf admitted to SSR Medical College, I shall abide by its rules and regulations.

3. I have read and understood all the provisions contained in the prospectus and here by agree to abide by these provisions

4. l. The parent/guardian of the applicant hereby declare that I am aware of the financial obligations of admitting my son/daughter/ward to SSR Medical College. I agree to pay the tuition and other fees payable to the institution as fixed by tne IOMIT from time to time. I also affirm and endorse the declaration made above by my son/daughter/ward

5. I agree that registration of this application does not confer any right on me in respect of selection for admission, which is solely left to the discretion of the institution.

DATE:-
PAYABLE AT MAURITIUS IN THE NAME OF "INDIAN OCEAN MEDICAL INSTITUTE TRUST,
Security Code:*

 
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