For Office Use only

Transaction ID: 9801017/MBBS

ALIGARH MUSLIM UNIVERSITY

Session: 2016-2017
Application Form for Admission to
MBBS/BDS

Affix the same

Photograph as you
have uploaded in
the Application Form

Faculty Of Medicine

Bank: 1170, DD/CR No.: 238526207, Date: 04-07-2016, Amount: 504.31

Nationality: INDIAN

Order of Preference of Branches/Courses/Centres:

__________________________________________________________________________________________________
1. MBBS 2. BDSB 3. -- 4. -- 5. -- 6. -- 7. -- 8. -- 9. -- 10. -- 11. -- 12. -- 13. -- 14. --

Preference for Test Centres:

__________________________________________________________________________________________________
1. ALIGARH 2. -NEET Roll No.: 60842671

Personal Details:
__________________________________________________________________________________________________
Name: KISA FATIMA
Date of Birth: 14-02-1997
Gender: FEMALE
Religion: ISLAM

Father's Name: ATHAR ABBAS ZAIDI

Mother's Name: SHAHANA PARVEEN

Details of Qualifying Examination:

Status & Special Categories:
__________________________________________________________________________________________________
Status: EXTERNAL
Examination: 12
Enrolment No.:
Roll No.: 14CSS2289
Hall: NA
Year of Passing/Appearing: 2015
Special Categories: 1. CA 2. CG 3. NA
Board/Univ.: 279
Marks Obt./Max. Marks: 454/500
Remarks (if any):
Course(s) Studied/Studying other than Qualifying Examination (Starting from the latest):
__________________________________________________________________________________________________
Course

Yr. of Passing/Appearing

Board/Univ.

Roll No.

Permanent Address:
Address for Correspondence:
__________________________________________________________________________________________________
Address: E 61 HAMMAD RESIDENCY
OKHLA VIHAR
NEW DELHI - 110025(DL)

Address: E 61 HAMMAD RESIDENCY

OKHLA VIHAR
NEW DELHI - 110025(DL)

Phone 1: 9873803584

Email ID: FATIMAKISA786@GMAIL.COM

Phone 2: 9718114764

Is hostel accommodation required? Y (Hostel accommodation is not guaranteed; it is subject to availability of seats in the hostel)
__________________________________________________________________________________________________
DECLARATION: I SOLEMNLY UNDERTAKE to accept and abide by the rules of the Aligarh Muslim University and all the decisions of the Academic
Council & other appropriate University bodies in regard to my admission. I hereby solemnly affirm that I have gone through the Guide to Admissions
& ORDINANCES/REGULATIONS pertaining to Ph.D and solemnly declare on oath that the entries made by me in the above columns are true to the
best of my knowledge and belief and if at any time, the entries are found incorrect, the admission may outrightly be cancelled and disciplinary action
may be initiated against me.
Transaction ID: 9801017/MBBS

04/07/2016-04:43

Thumb Impression
Male: Left Thumb, Female: Right Thumb

__________________________
Signature of the Candidate

FOR OFFICE USE ONLY

List of enclosures attached with the Application Form:

1.

DD/Cash Receipt in Original

2.

Self Attested copy of HS/SS Certificate in support of date of Birth

3.

Copies of Marksheets/Grade Sheets of all previous Examinations

passed/appeared including parts therein after passing High School

4.

If employed, copy of No Objection Certificate from the employer

Signature of Scrutiny Officer

5.

Documents in support of Internal Status/Spcl. Categ., if clamied*

6.

Copy of document(s), if rusticated/debarred or convicted by a court of law

Identity & Original Documents Verified

The candidate is eligible/not eligible for admission to

7.

________________________________________

8.

________________________________________

____________________________________
Remarks ____________________________

* Attach latest Marksheet/Document(s) in support, failing which your claim will be rejected

Verifying Officer ____________________

Hall Allotted:

Dept. of ___________________________
Date ____________________
Clearance by Proctor

DSW

Address Slips (for Office Use):

--------------------------------------------------------------------------------------------------------------------------------------Name: KISA FATIMA

Name: KISA FATIMA
Address: E 61 HAMMAD RESIDENCY
Address: E 61 HAMMAD RESIDENCY
OKHLA VIHAR
OKHLA VIHAR
NEW DELHI - 110025(DL)
NEW DELHI - 110025(DL)
Tel./Mobile: 9873803584
Tel./Mobile: 9873803584
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Name: KISA FATIMA
Name: KISA FATIMA
Address: E 61 HAMMAD RESIDENCY
Address: E 61 HAMMAD RESIDENCY
OKHLA VIHAR
OKHLA VIHAR
NEW DELHI - 110025(DL)
NEW DELHI - 110025(DL)
Tel./Mobile: 9873803584
Tel./Mobile: 9873803584
---------------------------------------------------------------------------------------------------------------------------------------

Transaction ID: 9801017/MBBS

(For Office Use only)

Aligarh Muslim University

Scan Card, 2016-2017
MBBS/BDS

Affix the same

Photograph as you

Name: KISA FATIMA

Address:
E 61 HAMMAD RESIDENCY
OKHLA VIHAR
NEW DELHI - 110025(DL)
Tel./Mobile: 9873803584

have uploaded in
the Application Form

Thumb Impression
Male(Left Thumb)/Female(Right Thumb)
Specimen Signature of the candidate

ACKNOWLEDGEMENT SLIP, AMU, Aligarh

Application form for admission to:
MBBS/BDS, 2016-2017
has been received.
App. No. is: _____________________
Transaction ID: 9801017/MBBS

To,
Name: KISA FATIMA
Address: E 61 HAMMAD RESIDENCY
OKHLA VIHAR
NEW DELHI - 110025(DL)
Tel./Mobile: 9873803584

POSTAL SLIP

(To be pasted on envelop containing the Application Form)

Application Form for Admission to

MBBS/BDS
To,
ASSTT./DY. CONTROLLER (ADMISSIONS)
ADMISSION SECTION, AMU,
ALIGARH - 202002 (UP)

From:
Name: KISA FATIMA
Address: E 61 HAMMAD RESIDENCY
OKHLA VIHAR
NEW DELHI - 110025(DL)
Tel./Mobile: 9873803584

9801017/MBBS

--------------------------------------------------------------------------------------------------Aligarh Muslim University

CANDIDATE'S SLIP

(Keep this Slip with you for future reference)

Course Applied for: MBBS/BDS
Transaction ID: 9801017/MBBS
_______________________________________________________________________________

INSTRUCTIONS

1. Please ensure that you have appended Photographs, Thumb Impression and Signature at the designated places on
the Application form.
Note: a) Use identical good quality color photographs taken not earlier than 3 months. The photographs should be taken preferably
wearing dark clothes on a white background.
b) Your Thumb Impression & Signature establish your identity hence, do not merely write your name in capital letters.

2. You must Ensure that all the documents along with Demand Draft is attached with the Application Form.
Note: Demand Draft (valid for 3 months) of the requisite amount should be drawn in favor of FINANCE OFFICER, AMU, payable at
Aligarh.

3. You must NOT make any type of correction(s) / modification(s) on the Application Form else your candidature may be
rejected.
4. Paste the 'POSTAL SLIP' given above on the A-4 size Envelope containing the Application Form and send it on the
Pre-Printed Address.
5. Please be a regular visitor to our website: www.amucontrollerexams.com which will provide you with necessary
updates regarding the status of your Application Form/Admission Test results etc.
6. Admit cards shall be available for download from the website. No Admit card shall be sent via postal mail.