Admission Opted for: GIPS-Guwahati/GIPS-Tezpur self ...
Transcript of Admission Opted for: GIPS-Guwahati/GIPS-Tezpur self ...
To be filled up and submitted for counselling and Admission Sl. No.…………
GIRIJANANDA CHOWDHURY INSTITUTE OF PHARMACEUTICAL SCIENCE-TEZPUR
(An Institute established under PPP model by Shrimanta Shankar Academy and Govt. of Assam)
1. Name of the applicant : in full (in block letters)
2. Sex (M/F) :
3. Date of Birth :
4. Father’s Name :
5. Mother’s Name :
6. Father’s Occupation :
7. Mother’s Occupation :
8. Family Income :
9. Postal Address :
10. Permanent Address :
11. Parent/Guardian’s Contact Details:
STD Code: Phone No:
Mobile No:
E-mail ID:
APPLICATION FORM
Admission Opted for: GIPS-Guwahati/GIPS-Tezpur self-sponsored/ GIPS-Tezpur Govt. quota
Admission sought in: D. Pharm/B. Pharm/B. Pharm (Practice)/M. Pharm/PhD.
Dekargaon, Tezpur, Sonitpur-784501
Azara, Hatkhowapara, N.H.-37, Guwahati- 781017
GIRIJANANDA CHOWDHURY INSTITUTE OF PHARMACEUTICAL SCIENCE (GIPS)
(A unit of Shrimanta Shankar Academy)
(SESSION-2021-2022)
12. Student's Contact Details:
Mobile No:
E-mail ID:
13. Nationality :
14. Religion :
15. Caste/ Category: Gen/SC/ST/OBC/MOBC/Others:
16. Details of Examination Passed :
Name of
the Exam
Name of Board/
University
Year of
Passing
Reg. No.
&
Roll No.
Total
Marks
Prescribed
Total
Marks
Obtained
% of
Marks
Obtained
HSLC
HS.
(10+2)
D. Pharm
B. Pharm*
M. Pharm#
GPAT*
*Applicable for only M. Pharm Candidates
#Applicable for only PhD Candidates
17. Details of marks obtained in H.S./10+2 or Equivalent (Sc.) (only for D. Pharm & B. Pharm)
Exam Marks secured in % of marks in aggregate of
Phys. Chem. Math. Bio. PCM PCB
HS/ 10+2 or
Equivalent (Sc.)
18. Proficiency in Co-curricular activities:
19. Preference of Branch (mention 1, 2, 3 in the box) (For M. Pharm Candidates Only)
Transaction No:
Date of Transaction:
Pharmaceutics Pharmaceutical Chemistry Pharmacology
20. Payment Details: Cash/Online: