9/7/2016 AIIMS

All India Institute of Medical Sciences
Ansari Nagar, New Delhi ­ 110608
Entrance Examination ­ 2016
Registration Form ­ AIIMS­PG MD/MS/MCH(6YRS)/DM(6YRS), January 2017

Candidate Profile Candidate ID: 112166 Registration No.: 109558 Registration Date: 07/09/2016

Name: HAIFA MARIAM Date of Birth: 08/04/1992

Gender: Female Marital Status: UNMARRIED

Father's Name: SHAHUL HAMEED MUNNIPPADY Category: OBC(NCL)

Mother's Name: ZAIBUNNISA KUKKAR Disability Status: No

Nationality: INDIAN Disability Option: ­­

Identification Mark(1): BLACK MOLE ON THE LEFT WRIST Identification Mark(2): BLACK MOLE ON THE
RIGHT FOREARM
Applied Under/Department: General/­­

Contact Details

Address for Correspondence: SAHEL, JEPPU MAJILA, KANKANADY, Permanent Address: HAIFAA, SUBHASH NAGAR 3RD CROSS, PANDESHWAR,
MANGALORE, Karnataka, India, 575002 MANGALORE, Karnataka, India, 575001
Mobile No(s): 1. 9686093906 ,        2. 0824­2416695 E­Mail ID: haifaa99@yahoo.com

Qualification Details

S. Qualifying Exam Name of Degree Institution University Date of Passing

No.
1 Undergraduate MBBS Father Muller’s Institute of Medical Education and Research, Mangalore RGUHS 15/06/2015

Academic Details

Marks Obtained: 2800 Maximum Marks: 5050 Percentage: 55.45

Internship Details

Internship Status: Undergoing Internship Start Date: 05/10/2015 Completion Date: 22/10/2016 No. of Days: 384

Medical Registration Details

Registration Type: Provisional Registering Authority: State Council Reg. Date: 05/10/2015 Reg No.: 3881

Valid Photo Identity (To be presented in original at the Examination Center along with Admit Card)

Nature of ID: Driving Licence ID No: KA 19 20100011030 Place of Issue: MANGALORE Issue Date: 26/07/2010 Valid Till: 25/07/2030

Payment Details

Mode: ONLINEPAYMENT Date: 07/09/2016 Transaction ID: 100012636604 Amount: 1000.00

Examination Center opted: Bengaluru

DECLARATION: I hereby declare that the information furnished by me in the Registration Form is correct and nothing has been concealed. In case any information
furnished by me is found to be false/incorrect/untrue than i shall be liable to civil/criminal prosecution and my claim to admission/appointment/registration/ service in
the Institute may be cancelled/terminated.

Candidate Signature Candidate Thumb

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