Genex College Of Pharmaceutical Science & Technology Chinsurah
ADMISSION FORM
(FOR OFFICE USE ONLY)
DATE :
ROLL NO:
(Office Use Only)
(USE CAPITAL LETTER ONLY)
NAME OF THE CANDIDATE:
*
FATHER’S NAME:
*
MOTHER’S NAME:
*
GUARDIAN’S NAME:
PRESENT ADDRESS
PRESENT ADDRESS:
*
VILL /CITY:
*
POST:
*
P.S:
*
DIST:
*
PIN:
*
PERMANENT ADDRESS
PERMANENT ADDRESS:
VILL /CITY:
POST:
P.S:
DIST:
PIN:
HOME DISTRICT (Where candidate resides for atleast 5 years till 31.12.2020):
STUDENT INFORMATION
GENDER:
*
RELIGION:
*
CATEGORY:
DATE OF BIRTH:
*
PLACE OF BIRTH:
*
AGE ON ADMISSION DATE:
*
NATIONALITY:
*
AADHAR CARD NO:
*
MARITAL STATUS:
*
EMAIL ID:
*
MOBILE NO (Candidate):
*
MOBILE NO(Gurdian):
*
EDUCATIONAL QUALIFICATION:
*
ATTACHED BELOW DOCUMENTS
Mp Admit:
Mp Marksheet:
Hs Marksheet:
Grade Marksheet:
Reg Certificate If BU:
Masters marksheet:
Aadhar Card:
Cast Certificate(If any):
DETAILS OF HS OR EQUIVALENT EXAMINATION:
*
INSTITUTION ADDRESS & PINCODE
NAME OF THE BOARD / COUNCIL
YEAR OF PASSING
STREAM
ROLL NO
MARKS DETAILS
AGGREGATE
% OF MARKS
ENG
COMP I
COMP II
COMP III
LOCAL GURDIAN’S NAME & ADDRESS WITH MOBILE NO:
LOCAL GURDIAN’S SIGNATURE:
*
LIST OF VISITORS:
1.
2.
3.
Self Declaration: -
I hereby declare that the information given in the form is accurate to the best of my knowledge.
Signature of the Candidate
*
Signature of Gurdian
*