9/2/2015

ApplicationformPrintout

[STUDENTCOPY]
ApplicationFormNumber:307520

Smt.KishoritaiBhoyerCollegeofPharmacy
Kamptee,Kamptee
RashtrasantTukadojiMaharajNagpurUniversity

MasterofPharmacy(withCredits)Regular20122013
Onwards(New)PharmacologyFinalYear
(MediumEnglish)

ApplicationForm307520

1.PersonalInformation
NameofApplicant:

NIKITASUBHASHDAMBALE

Father's/Husband'sName(MiddleName):

SUBHASH

DateofBirth:

16May1991

Gender:

PlaceofBirth:

NAGPUR

MobileNumbers:8806385050,7798835793

AddressforCorrespondence:

MUREMEMORIALHOSPITALCAMPUS,MAHARAJBAGHROAD,SITABULDI,NAGPUR,City:NAGPUR,
Taluka:NagpurCity,District:Nagpur,State:Maharashtra,Country:India,Pin:440001

ContactNumber:

NotAvailable

Female

Mother'sFirstname:

ANITA

MaritalStatus:

UnMarried

EmailId:animary83@yahoo.in

Reservation/SpecialGroupInformationofApplicant:
EnrollmentNumber:

RTMNU/A10/44202

ExamEvent:

Mar2015

SeatNumber:76149

2.PapersSelectedfor:FinalYear
MasterofPharmacy(withCredits)Regular20122013Onwards(New)PharmacologyFinalYearSemIII
3MPH15Seminar(PrestnopsisPresentation)

3MPHE20D2HerbalCosmetics

3MPLS13MolecularPharmacologyandToxicology

MasterofPharmacy(withCredits)Regular20122013Onwards(New)PharmacologyFinalYearSemIV
4MPL17Dissertation

4MPL18SeminaronDissertation

4MPL19VivaVoce

3.EducationalDetailsSection
Nameof
Examination
SECOND
SEMESTER
MASTEROF
PHARMACY

NameofBoard/University
RashtrasantTukadojiMaharaj
NagpurUniversity

Dateof
Passing

SchoolName
PRIYADARSHANIJ.L.CHATURVEDI
COLLEGEOFPHARMACY

Aug2015

Grade/Total
Marks
SeatNumber
Obtained
470/650

Qualifying
Exam

76149

4.RequiredDocumentsandCertificatesSection(Pleasetickmarkthedocumentthatyouhaveattachedtothisform)
StatementofMarksofFirstYear/Semester

StatementofMarksofSecondYear/Semester

SoM/SoGofQualifyingExamination

DomicileCertificate.

5.DeclarationbyApplicant
Iherebydeclareandagreethat,
1. ThisApplicationmostlyincludeallthemajorCoursesandCollegesoftheUniversity.However,iftheCoursesandCollegesoftheUniversityarenot
listedintheapplication,thenitismyresponsibilitytocontacttheCollegeseparatelyforapplyingfortheCoursesthatarenotlisted.
2. Iknow,UniversitymayaddaffiliationtonewCollegesoraffiliatenewCoursetoexistingCollegesaftermyapplication.Itwillbenotifiedthrougha
Corrigendumonportal.ItismyresponsibilitytocheckthesameregularlyandapplyforthenewlyaddedCourse/College,ifinterested.
3. Ihavereadtherulesrelatedtoadmissionandtheinformationfilledinbymeinthisformisaccurateandtruetothebestofmyknowledge.Iwillbe
responsibleforanydiscrepancy,arisingoutoftheformsignedbymeandunderstandthat,intheabsenceofanydocument,thefinaladmissionwill
notbegrantedand/oradmissionwillstandcancelled.

IamawareoftheAntiRaggingActandIstatethatIwillabidebyalltherulesandregulationofthesaidAct.
Place:
Date:

SignatureoftheApplicant:

6.DeclarationbyParent/Guardian
Ihavepermittedmyson/daughter/wardtoapplyinyourCollege.Theinformationsuppliedbyhim/heriscorrecttothebestofmyknowledge.Ihave
acquaintedmyselfwiththerulesandfees/duesrelatedtotheCourse.
Place:
Date:SignatureoftheGuardian:
7.ForCollegeUseOnly
Designation

Remarks/Particulars/Recommendations

SignatureandDate

AdmissionClerk
Admission
Committee
Accountant/Cashier CashReceived:Rs.

ReceiptNo.:

Registrar/Office
Superintendent
Note:Afterfillingtheapplicationform,submitthisprintouttotheCollegewiththerequireddocuments.Studentshouldobtainthesignandsealofthe
College.Otherwiseapplicationwillnotbeconsideredvalidandeligible.

http://rtmnuadmission.digitaluniversity.ac/OnlineAdmissions/PrintApplication.html

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9/2/2015

ApplicationformPrintout

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x

http://rtmnuadmission.digitaluniversity.ac/OnlineAdmissions/PrintApplication.html

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9/2/2015

ApplicationformPrintout

[SUBMISSIONCOPY]

ApplicationFormNumber:307520

Smt.KishoritaiBhoyerCollegeofPharmacy
Kamptee,Kamptee
RashtrasantTukadojiMaharajNagpurUniversity

MasterofPharmacy(withCredits)Regular20122013
Onwards(New)PharmacologyFinalYear
(MediumEnglish)

ApplicationForm307520

1.PersonalInformation
NameofApplicant:

NIKITASUBHASHDAMBALE

Father's/Husband'sName(MiddleName):

SUBHASH

DateofBirth:

16May1991

Gender:

PlaceofBirth:

NAGPUR

MobileNumbers:8806385050,7798835793

AddressforCorrespondence:

MUREMEMORIALHOSPITALCAMPUS,MAHARAJBAGHROAD,SITABULDI,NAGPUR,City:NAGPUR,
Taluka:NagpurCity,District:Nagpur,State:Maharashtra,Country:India,Pin:440001

ContactNumber:

NotAvailable

Female

Mother'sFirstname:

ANITA

MaritalStatus:

UnMarried

EmailId:animary83@yahoo.in

Reservation/SpecialGroupInformationofApplicant:
EnrollmentNumber:

RTMNU/A10/44202

ExamEvent:

Mar2015

SeatNumber:76149

2.PapersSelectedfor:FinalYear
MasterofPharmacy(withCredits)Regular20122013Onwards(New)PharmacologyFinalYearSemIII
3MPH15Seminar(PrestnopsisPresentation)

3MPHE20D2HerbalCosmetics

3MPLS13MolecularPharmacologyandToxicology

MasterofPharmacy(withCredits)Regular20122013Onwards(New)PharmacologyFinalYearSemIV
4MPL17Dissertation

4MPL18SeminaronDissertation

4MPL19VivaVoce

3.EducationalDetailsSection
Nameof
Examination
SECOND
SEMESTER
MASTEROF
PHARMACY

NameofBoard/University
RashtrasantTukadojiMaharaj
NagpurUniversity

Dateof
Passing

SchoolName
PRIYADARSHANIJ.L.CHATURVEDI
COLLEGEOFPHARMACY

Aug2015

Grade/Total
Marks
SeatNumber
Obtained
470/650

Qualifying
Exam

76149

4.RequiredDocumentsandCertificatesSection(Pleasetickmarkthedocumentthatyouhaveattachedtothisform)
StatementofMarksofFirstYear/Semester

StatementofMarksofSecondYear/Semester

SoM/SoGofQualifyingExamination

DomicileCertificate.

5.DeclarationbyApplicant
Iherebydeclareandagreethat,
1. ThisApplicationmostlyincludeallthemajorCoursesandCollegesoftheUniversity.However,iftheCoursesandCollegesoftheUniversityarenot
listedintheapplication,thenitismyresponsibilitytocontacttheCollegeseparatelyforapplyingfortheCoursesthatarenotlisted.
2. Iknow,UniversitymayaddaffiliationtonewCollegesoraffiliatenewCoursetoexistingCollegesaftermyapplication.Itwillbenotifiedthrougha
Corrigendumonportal.ItismyresponsibilitytocheckthesameregularlyandapplyforthenewlyaddedCourse/College,ifinterested.
3. Ihavereadtherulesrelatedtoadmissionandtheinformationfilledinbymeinthisformisaccurateandtruetothebestofmyknowledge.Iwillbe
responsibleforanydiscrepancy,arisingoutoftheformsignedbymeandunderstandthat,intheabsenceofanydocument,thefinaladmissionwill
notbegrantedand/oradmissionwillstandcancelled.

IamawareoftheAntiRaggingActandIstatethatIwillabidebyalltherulesandregulationofthesaidAct.
Place:
Date:

SignatureoftheApplicant:

6.DeclarationbyParent/Guardian
Ihavepermittedmyson/daughter/wardtoapplyinyourCollege.Theinformationsuppliedbyhim/heriscorrecttothebestofmyknowledge.Ihave
acquaintedmyselfwiththerulesandfees/duesrelatedtotheCourse.
Place:
Date:SignatureoftheGuardian:
7.ForCollegeUseOnly
Designation

Remarks/Particulars/Recommendations

SignatureandDate

AdmissionClerk
Admission
Committee
Accountant/Cashier CashReceived:Rs.

ReceiptNo.:

Registrar/Office
Superintendent

http://rtmnuadmission.digitaluniversity.ac/OnlineAdmissions/PrintApplication.html

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