Application Number:

2030749

PROGRAMS
Course Groups - [Courses]

Medical, Dental & Pharmacy - [BDS & MBBS]

Test Centers

Delhi,Gurgaon

BASIC INFORMATION
First Name

Pritam

Email ID

bijayaketan.panigrah
i@gmail.com

Last name

Panigrahi

Mobile Number

9582782220

Parent's Name

Dr. Bijaya Ketan

Panigrahi

Phone Number

9818275326

Gender

Male

Address

Warden house
Aravali hostel
IIT delhi , Hauz khas

Nationality

Indian

Student Photo

Student Signature

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EDUCATION QUALIFICATION

University Name

Suraj Bhan DAV public Qualifying Exam

school

12th

Board/University

cbse

Year of Passing

2015

ONLINE(CCAvenue)

Payment Amount

1600

PAYMENT DETAILS

Payment Type

OTHER INFORMATION
Date of Completion of
Internship

Are you a diploma

holder?

Exam Name

Exam Score

Registration No:

Completion Year

I confirm that I fulfil the eligibility criteria for the course I am applying for.
I understand that no refund will be made on the application fee if I am not eligible for the programmes I am applying for.

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DECLARATIONS

I hereby declare that all the particulars stated in this application form are true to the best of
my knowledge and belief. I have read and understood all provisions of admissions and agree
to abide by them. I also affirm that I fulfil the eligibility requirements for the course/s applied.
In the event of submission of fraudulent, incorrect or untrue information or suppression or
distortion of any fact, like educational qualification, marks, nationality etc. I understand that my
admission/degree is liable for cancellation. I further understand that my admission is purely
provisional subject to the verification of the eligibility conditions. NOTE: 1. Please keep a copy
of the filled in application for future reference. 2. Application number must be quoted in all future
correspondence. 3. Please mail the printed copy of the completed application form along with
the DD/Challan (if payment is not via Credit / Debit Card) to: The Director, Admissions, Manipal
University, Manipal - 576104

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