MDM College-Registration Form

Personal Details :

Adhar Card Number

PAN Card Number

Voter ID Number

First Name

Middle Name

Last Name

Mothers Name

Date Of Birth

Birth Place

Gender

Maritial Status

CitizenShip

Religion

Category

Blood Group

Are You Physically Challanged ?

YES NO

If Physically Challanged

Contact Number

Email ID

Admission Details :

Course Applied For

Stream Applied For

Year Applied For

Applying For Concession

Current Address Details :

State

District

Tehsil

Village

Street/House No.

Pincode

Permanent Address Details :

Is Current Address is same as Permanent Address

State

District

Tehsil

Village

Street/House No.

Pincode

Educational Details :

Name Of Exam

Name Of Board/University

Name Of College/School

Date Of Passing

Exam Seat No.

Degree Passing Certificate No

Grade/Total Marks Obtained

Out Of Marks

Qualifying Exam

Guardian's Details :

Name Of The Guardian

Occupation Of The Guardian

Annual Income Of The Guardian

Relationship Of The Guardian with Applicant

Guardian Contact No.

Attached Documents and Certificates :

Sr No.	Name of Documents / Certificates	Original/Attested True Copy
1.	Passing Certificate Of STD 10th	Attested True Copy
2.	Passing Certificate Of STD 12th Statement Of Marks STD 12th	Attested True Copy
3.	Leaving Certificate	Original
4.	Certificate Of Caste With Category	Attested True Copy
5.	Non Creamy Layer Certificate	Attested True Copy
6.	Affidavit for changed name / Marriage Certificate Govt. Gazette	Attested True Copy
7.	Domicile Certificate	Attested True Copy
8.	Certificate Of Physically Challenged	Attested True Copy

Other Information :

Mother Tounge

Employment Status

Do You Wish To join NCC/NSS?

Do You like To apply for Hostel?

Hobbies And Other Interrests

Games and Sports Participation ?

Personal Identification Marks 1

2

Declaration By Student :

I here by declare that, I have the rules related to admission and the information filed in by me in this form is accurate and true to the best of my knowledge. I will responsible for any discrepancy, arising out of the from signed by me and i undertake that, in absence of any document the final admission will not be granted and / or admission will stand cancle.
Place:

Date:

Signature Of Student

Declaration By Guardian :

I have permitted my son/daughter/ward to join your college. The information supplied by him/ her is correct to the best of my knowledge. I have aquinted myself with the rules and fees, dues to my son/daughter/ward and to see that he / she observes.
Place:

Date:

Signature Of Guardian

Remark :

Remark