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					  APPLICATION FORM FOR ADMISSION TO THE POST GRADUATE DIPLOMA IN
                MEDICAL ENTOMOLOGY COURSE, 2002-2003
====================================================================

1. Name (In Block Letters)……………………………………………

2. Date of Birth:………………Sex………..Nationality……..………

3. Do you belong to Schedule Caste/Tribe……………..……………
                                                                               Affix one
   (Attach copy of community certificate)                                     photograph
                                                                             signed by the
4. Name of Father/Guardian……………………………..…………..                             candidate on the top
                                                                                margin
5. Address for Communication………………………………………

   …………………………………………………………………….…

6. Category under which you are applying:

   i) Category I (Open General)           ii) Category II (In-service)

7. Demand Draft: Name of the bank & branch: ………………………
   Particulars : DD amount Rs………….. No………………… date………..

                      (XStd/SSLC/CBSE)       (HSC/PUC/         Degree Course        P.G. Course
8. Details of Study       Equivalent*      Intermediate)*          B.Sc.*              M.Sc.*

Board/ University

Subjects studied

Course duration


Period of Study

Register Number

% Marks/Class
* Attach attested copies of mark sheets, provisional/degree certificate

                          DECLARATION BY THE APPLICANT

I hereby affirm that the information given by me in the application is true and no relevant
fact is suppressed.


Place & Date:                                                   Signature of the Applicant

				
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