CgÉ ªÉÊzÀåQÃAiÀÄ ªÀÄAqÀ½, ¨ÉAUÀ¼ÀÆgÀÄ PARA MEDIC AL BO ARD MEDICAL BOARD Lakshmi Complex, First Floor # 5, New No.40/20 A, Opp Vani Vilas Hospital, Bengaluru-560 [email protected] Ph: 080-26702159/3922 Fax : 080-26705410, Website : www.pmbkarnataka.org ANNUAL EXAMINATION APPLICATION FORM R egular Regular ................. R epeat er Repeat epeater (Application should be filled by the Candidate only) NAME OF THE INSTITUTION AND ADDRESS SEAL Affix Latest Uniform Photo Attested by the Principal DETAILS OF THE CANDIDATE REGISTER NUMBER : NAME OF THE CANDIDATE : (As per Xth Std. Marks Card) FATHER’S NAME : (As per Xth Std. Marks Card or Certificate) AGE : Name of the Course : Certificate Cource SUBJECT Q.P. CODE EXAMINATION FEES For Repeaters Enclosures YEARS SEX: M F YEAR OF PREVIOUS APPEARANCE: 1nd Year Diploma SUBJECT Q.P. CODE Final Year Diploma SUBJECT Q.P. CODE : Rs.900/- for fresh Candidate : 1. Rs.300/- for 1 Subject. 2. Rs.500/- for 2 Subject. 3. Rs.900/- for more then 2 Subject : 1. SSLC and PUC Xerox copy of Marks Card (for Freshers only) 2. One Uniform Photo to be Enclosed (Name of the Student should be written on the reverse side of the photo) 3. Xerox Copy of All Previous Marks Card 4. If any Change of Course/ College, enclose Xerox copy of the permission given by the PARA MEDICAL BOARD, Bengaluru. DD No. DD Date: Da te: Date: Signa tur e of the Candida te Signatur ture Candidate CERTIFICATE (To be filled in by the Principal of the Para Medical Institute) 1. Percentage of Attendance in Theory: 2. Percentage of Attendance in Practicals : 3. Has the student passed in the : Yes No Internal Assessment ? (Information furnished is checked and found correct) Signature of the Principal with Institution Seal Date: FOR OFFICE USE ONLY Application Verified by : Remarks : ELIGIBLE / NOT ELIGIBLE