Download OMM Registration Form

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Medical|IIT-JEE|Foundations
APPLICATION FORM
(Divisions of Oasis Educational Services Pvt. Ltd.)
(for Official use only)
Roll No. Allotted:
Form Checked by:_____________________________________Employee Code:___________Signature:_______________Date:____________
Please fill this Form with a Black / Blue pen in BLOCK Letters only
Application Form No.________________
1. Details about the Student:
First Name
Middle Name/Initials
Surname
a) Name of the Student________________________________________________________________
b) Date of Birth____________________________(DD/MM/YYYY)
c) Gender :
Male
(DO NOT STAPLE)
Female
Paste your
recent passport size
color photograph here.
d) Class* Presently Studying in the Current Academic Year (AY)
* If Class 8th fill 08, Class 9th fill 09, Class 10th fill 10, Class 11th fill 11, Class 12th fill 12, Class 12th pass fill 13)
Carry one additional
photograph for
admit card
e) Last Annual Exam / Board Exam Aggregate Marks (%) or Grade
f) Stream {Please tick (ü)}:
Medical
2.
Engineering
Foundation
Details about the School Presently Studying in / Last Attended:
(a)
School Name & Address __________________________________________________________________________________________
________________________________________________________________________City/Town ___________________________________
____________________________Pin Code ___________________ State_______________________ Tel. No.__________________________
(b)
Board (School is affiliated to) ____________________________________ (c) Your Current / Last Class Rank in your School __________
(d)
Name of your School Principal_______________________________________________________________________________________
(e)
Name of your Subject Teacher: Mathematics___________________________________ Physics __________________________________
Biology______________________________________ Chemistry_________________________________
3. Communication Details:
(a) E-Mail IDs and Mobile Nos.
E-Mail ID (Please Fill in BLOCK Letters Only)
Mobile Number
Student
Father
Mother
What is your preferred e-mail ID
Student
Father
Mother
What is your preferred Mobile No.
Student
Father
(c) Permanent Address:
(b) Correspondence Address:
(Please do not write your /your Father's name in these address boxes. Fill the address only within the space provided in boxes.)
Pin
Pin
Mother
4. Details about Parents (in BLOCK Letters only)
Father's / Legal Guardian Name___________________________________________________________________________________________
Qualification____________________________Occupation ___________________________ Designation _______________________________
Office Name / Address __________________________________________________________________________________________________
_________________________________________________________ Contact No’s _________________________________________________
Mother’s Name ________________________________________________________________________________________________________
Qualification ___________________________ Occupation ___________________________ Designation ________________________________
Office Name / Address __________________________________________________________________________________________________
________________________________________________________ Contact No’s __________________________________________________
5. Details of your Scholastic Achievements in any of these exams {Please tick (ü) & give its details)}:
NTSE
JSTSE
NSEJS
KVPY
Olympiads
AIPMT
JEE-Main
JEE-Adv.
Others
Details
6. Are you taking any specialized Coaching for Competitive Exams {Please tick(ü)} : Yes
No
Since (Year)
If Yes, Name of your Coaching Institute
Your Overall Rank in your Coaching Institute.
7. Details about Your Sibling:
Name 1 (Brother / Sister)
Class presently studying in
Name 2 (Brother / Sister)
Class presently studying in.
8. How did you come to know about Oasis OMM/OSAT Programs ? {Please tick (ü)} :
Newspaper Advt.
Social Media
Hoardings
Radio
News Paper Insert
Banner / Poster
Present / Ex-OASIS Student
Website
Friends / Relatives
E- Mailer
Through OASIS Faculty
if other source (please specify)
Declaration by the Student / Parent / Guardian
• I / we have received & read the Terms & Conditions and promise to abide by the same.
• Registration Fee will not be refunded in any case of transferred to any other Admission Test Date.
• I authorize OASIS Gurgaon to contact and send communication / information by SMS, e-mail, post on the above mentioned
communication details given by me.
Fee Paid `
200/-
Dated
in Cash / DD / Pay Order No.:
Bank
I / we hereby declare that the information furnished on this Application Form is correct to the best of my knowledge and belief.
Date:
(Signature of Student)
(Name of Student)
(Signature of Parent/Guardian)
(Name of Parent/Guardian)
OASIS
An Oasis group Gurukul
OASIS
An Oasis group Gurukul
SIS EDU
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AIPM
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An Oasis group Gurukul
OASIS GURGAON :
M-6, 2nd Floor, Aptech Building,
Near SBI, Old DLF Colony,
Sector-14, Gurgaon-122001
Tel. : 0124-4253725/9650069765,
Email : [email protected],
Web : oasisgurgaon.com
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OASIS
Medical|IIT-JEE|Foundations
(Divisions of Oasis Educational Services Pvt. Ltd.)

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