DENTACME AIM HIGH ACHIEVE MORE

Leading coaching academy for MDS, NBDE ,NDEB & ADC Preparation

REGISTRATION FORM
FOR OFFICE USE
PASTE YOUR ONE
Registration Number:…………………………………………….. PASSPORT SIZED
PHOTOGRAPH
Signature of Center Coordinator: ……………………………
HERE AND SUBIT
ONE TO THE
EXAMINATION CENTER: …………………………………………………………… CENTER

First Name
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Last Name
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Email:
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Father’s Name
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Mother’s Name
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Date of Birth ……………………… (D/ M/Y) Gender …………….. (M/F)

Reservation (Y/N): SC ……. BC ……. UR ……. ST….. PH ……. Others ………

Mobile Number
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Whatsapp Number
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Parent College
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BDS Completion:

Year: / / Final Year Marks %……… Aggregate Marks %: ………

Permanent Address:
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State: Pin Code:

Correspondence Address (If different from permanent address)

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State: Pin Code:
 COURSE CHOOSEN

MDS………………… NBDE………………. NDEB…………

ADC………………

PAYEMENT MODE CHOOSEN

Cash …. (Y/N) NEFT …… (Y/N) Cheque ……. (Y/N) DD …… (Y/N)

Note: Whatever be the mode of payment, please attach receipt of the fee deposited with
this form as a proof and it will be confirmed as soon as possible.

DECLARATION: I understand that the registration fee paid will not be refunded under any
circumstances and also I agree to receive SMS and notifications from DENTACME.

DATE: Signature of Applicant: