5/12/2015 KIMS UNIVERSITY KAIET-2015

KRISHNA INSTITUTE OF MEDICAL

SCIENCES DEEMED UNIVERSITY Application
(Declared U/s of UGC Act, 1956 vide notification No.F.9-15/2001-U.3 of Ministry of Human No.
Resource Development, Govt. of India)
Karad, Dist.Satara (Maharashtra State), Pin: 415110
Phone: (02164) 241555/6/7/8, Fax: (02164) 243272/242170 1411140
WebSite: www.kimsuniversity.in
KAIET - 2015 APPLICATION FORM for
(MBBS & BDS)

Course Preference: MBBS

Candidate's Name : KAKADE POOJA BABANRAO

Father's/Mother Name : BABANRAO SURYABHAN KAKADE

Date of Birth : 23/08/1995

Gender : Female

Address : DATTA NAGAR LAKHALA WASHIM

Paste Your Recent Color
TQ. DIST.WASHIM Photograph as per the
instructions in the
MAHARASHTRA
brochure.
City : WASHIM Pin : 444505

State : MAHARASHTRA

Mobile Number : 9763282177 Tele. No. : 07252-233977

Category : OBC

Choice of Centre : 14-NAGPUR

Signature of the Candidate
Email : santosh456@gmail.com

Demand Draft Details : Bank : BANK OF MAHARASHTRA

D.D. No : 881739 D.D. Amount : Rs. 1500/- D.D. Date : 12/05/2015

De claration

1. I hereby declare that the above information is true and complete to the best of my know ledge. I am aw are that if any
information herein is found to be incorrect or incomplete, my application form w ill be rejected / admission w ill be cancelled.
2. If admitted to this Institution I shall abide by its Rules & Regulations.
3. I have read and understood all the provisions contained in the brochure and hereby agree to abide by these provisions.

Le ft Thum p Print of the Candidate Signature of the Candidate

I, the parent / guardian of the applicant hereby declare that I am aw are of the financial obligation of admitting my child / w ard to
K.I.M.S.D.U., Karad. I agree to pay the tuition and other fees payable to the institution as fixed from time to time as per the rules of
K.I.M.S.D.U., Karad. I also affirm and endorse the declaration made above by my child / w ard.
Place :
Date : Signature of the Pare nt /
Guardian

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5/12/2015 KIMS UNIVERSITY KAIET-2015

Authe ntication by the colle ge w he re the candidate has las t s tudie d/appe are d or by Gaze tte d office r.

Mr./ Miss. ............................................................................................................... born on ............................. w as a bonafide student of this

institute / is know n to me since last .................. years and has passed/appeared his / her examination held in Month.............Year .........

Signature and Se al of the He ad of the Ins titution / Gaze tte d Office r

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