Admission – Multispeciality Hospitals in Chennai

1. Full Name (In Capital Letters) *

First

Last

2. Gender

Male
Female
Transgender

3. Age *

4. Mother’s Name

5. Nationality

6. Blood Group

7. Mother Tongue

8. Religion

9. Community / Caste

10. Email ID

11. Mobile Number *

12. Applied Course - BHARAT SEVAK SAMAJ (12th pass or dropout any group)

Diploma in Dialysis Technology
Diploma in Accident & Emergency Care Technology
Diploma in Medical Laboratory
Diploma in General Health Care and Meternity Assistant
Diploma in X-Ray and Imaging Technology

13. Permanent Address: *

14. Father’s Name (Guardian’s Name & Relationship)

15. Name & Address of the Parent/Guardian:

16. Occupation of the Parent/Guardian

17. Language Known ( Speak / Read / Write)

Tamil
English
Hindi
Others

Board/ University *

Group/ Division *

% OF Marks *

Years of Passed *

Declaration By The Applicant

I hereby declare that information furnished is true and correct.

I will abide by the rules and regulations of the institute given below

1. Students should be punctual and regular in attendance

2. Misconduct: Students found violating the rules and regulations and found irregular in punctuality, attendance and conduct are liable for removal from the institute

3. Medium of Instruction: Student will be taught in English, explanation will also be given in Tamil.

4. Punctuality & attendance 85% attendance is compulsory to write the examination

5. Right to Suspend: right to suspend/expel/debar a student, in case of any serious disciplinary issues management has the rights to maintain the good name of the institute.

6. The use of mobile/cell phone is strictly prohibited in the class Room