BANGALORE

UNIVERSITY

Jnanabharathi, Bangalore 560 056, Karnataka State

SCHOOL OF NATURAL SCIENCE D.D. No. : Date of Issue : Bank :

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Application for UGC Innovative PG Diploma in Clinical Embryology & Assisted Reproductive Technology Course : PG Diploma in Clinical Embryology & Assisted Reproductive Technology

M.B.B.S. B.V.Sc. M.Sc

Qualifying Examination
Zoology Biotechnology Life sciences Biological Sciences Molecular biology Applied genetics

Candidate applied under Sponsored seats

Government Govt. Recognized Private Foreign National Others
Certificate of sponsorship to be enclosed

PERSONAL RECORD 1. Name of the Applicant Surname .. Name .. 2. Fathers Name ... Mothers Name .. Address . . . Phone : 3. Category to which the applicant belongs (Certificates to be enclosed)
GM SC ST Cat-I IIA IIB IIIA IIIB

ACADEMIC RECORD 4. Institution last attended 5. Month & Year of passing the qualifying exam .. 6. Previous Examination Passed and Name of the University / Authority

7. Marks obtained in the qualifying examination Degree:

Subject/ Papers Max. Marks Marks obtained

Total

I have read the admission conditions and instructions and relevant ordinances as given in the Admission Pack and undertake to abide by them. Date: Place:

Signature of the Applicant

Note: 1. All the columns should be filled up. Incomplete Applications will be rejected. If not applicable, marks it as, Not Applicable against the said column. 2. Photo copies of the academic documents along with Bank Challan/DD should be enclosed.

ACKNOWLEDGEMENT

Received the Application of Sri/Smt. ... for Application No. .. being for .......... course at .. Date :

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Signature & Seal of the Receiving Officer

Remarks on the enclosures