MMM ACADEMY OF MEDICAL SCIENCES (A Unit of Madras Medical Mission) No, 9, Block No. 11, Kannadasan Salai, Mogappair East, Chennai -600037,Phone : +91 – 44- 26560835/37/38, 26565886, 26561801 Mail : [email protected], [email protected], Website : www.mmmchs.org,www.mmm.org.in BS.PHYSICIAN ASSISTANT - COLLEGE APPLICATION FORM (In collaboration with Birla Institute of Technology & Science (BITS) Prospectus No :………………………. 1. NAME OF THE CANDIDATE:……………………………………………………………………….. 2. Date of Birth………………………………..Age (in years) :…………………………………….. 3. Nationality:……………………… Religion & Community Name ………………………… 4. Community OC 5. Sex : Male BC MBC/DNC SC/ST Others Female 6. Physical Condition : Normal / Disabled., If disabled specify……..……………………. 7. Mother Tongue:……… 8.Blood Group:………9.Parents Occupation:…………………. 10. School Last studied:………………………………………………………Board……………………. 11. Address for Communication(Permanent): ………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………… 12. Address for Communication (Temporary): ………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………… Requirement of hostel: Yes/No Phone Number of Parents/Guardian : ……………………………………………… Please note: The application form to register for the programme has to be downloaded at the Birla Institute of Technology & Science (BITS) website and sent to BITS-PILANI, Application is available at http://www.bits-pilani.ac.in/university/wilp/OtherCollabProgrammes