Application No:

Date of receipt :

Amrita Institute of Medical Sciences

Hall ticket no :

AMRITA SCHOOL OF PHARMACY, KOCHI - 682041

APPLICATION FOR ADMISSION TO B.PHARM COURSE 2014
Paste one recent passport size face close up color photograph self attested by the candidate Paste : Do not pin or staple

1.

Name of the candidate : ............... ((IN BLOCK LETTERS) (AS IN YOUR SCHOOL RECORDS) Sex : Male Female Date of Birth:

Do you belong to SC ST OEC If yes, Name of the casteand Community..(attach certificate of caste) 2. Academic Record Name of the institution (with place)from which candidate passed his/her plus two Course . Subjects Physics Chemistry Biology Biotechnology/ Computer Science TOTAL English Details of +2/Higher Secondary Marks Marks Scored Out of Percentage

3.

Address for communication: Pin.. Ph. No(with STD code): e-mail id

4.

Fathers name : Occupation :

Office address : . Ph. No(with STD code): e-mail id Mothers name :.. Occupation :.

Office address : . Ph. No(with STD code): e-mail id How did you come to know about AMRITA ? .. .. 5. Reason for choosing B.Pharm course ? 6. Reason for choosing AMRITA ? . .
Indicate (by darkening the column) whether you would like to be considered for Merit Management

Joint Declaration by the CANDIDATE AND THE PARENT

We hereby declare that all information furnished in the Application are true to the best of our knowledge and belief. We are also aware that if any statement made herein is found to be incorrect at any time either before or after admission , Principal, Amrita School of Pharmacy has the right to reject the application and may cancel the admission if at all admitted. We are also aware of our financial obligations to AMRITA SCHOOL OF PHARMACY, in case the candidate gets admission to the Pharmacy School and we undertake to pay the tution , hostel, mess and other fees as fixed by the institution from time to time. We also undertake to strictly adhere to the rules and regulations of the institution and agree to abide by the decision of the Principal, Amrita School of Pharmacy and Director Health Sciences Campus in all matters of admission and thereafter.

Signature of the Candidate: Date:

Signature of the Parent :

Enclosures 1. Mark list of qualifying examination (photocopy attested) 2. Demand draft of Rs.500/- drawn in favor of Amrita Vishwa Vidyapeetham payable at Kochi. 3. If belonging to SC/ST/OBC, certificate from the concerned authorities.
Please send your application to : Office of Dean of Research, Amrita Health Sciences Campus, Ponekkara, Kochi, Kerala 682041 :Tel: 0484-400-8750/7904/7903 Please mention on the envelope Attn: Pharmacy Admissions