(please save this as a text file first, fill it, and send it to pratishtana@yahoo.com)

Information Sheet
1. Name of the applicant :

2. Date & Place of Birth :

3. Father's Name :
 
   Occupation :

4. Mother's Name :
 
   Occupation :

5. Annual income of the family :

6. Residential Address :
 

   Telephone No. :

7. Name & Address of the Local guardian :
 

   Telephone No. :

8. Relationship with the guardian :

9. Native reference :
   1) Name
   2) Occupation
   3) Contact No.
   4) Address


10. Details of previous exam :	
	Place		 	Year 	% of marks
   SSLC      
   PUC 

11. Details of present Course  : BE / MBBS / BDS / MCA / Any Other (Specify)
    Name of the Institution :

	I Sem.    II Sem.  III Sem.    IV Sem. V Sem. VI Sem. VII Sem. VIII Sem.
  Marks