Rajiv Gandhi University of Health Sciences, Karnataka
Master of Public Health
Application Form for Entrance Examination 2019
Name of the Applicant(as per SSLC/10th marks card) :
Father's Name :
Mother's Name :
Date of Birth :
(dd/mm/yyyy)
Gender :
(select)
Female
Male
Transgender
Place of Birth :
Place of Birth - District :
Place of Birth - State :
Nationality :
( Select:)
Indian
NRI
Foreign
Permanent Address with Pin Code:
Address for Communication with Pin Code :
e-mail :
Phone :
Mobile :
Category:
echo
( select)
echo
GM
echo
I
echo
IIA
echo
IIB
echo
IIIA
echo
IIIB
echo
SC
echo
ST
Do you claim reservation under Hyderabad Karnataka Quota (371 J)?:
echo
(select)
echo
NO
echo
YES
Religion:
Caste:
Sub Caste:
*
Qualifying Exam. :
echo
( select)
echo
MBBS
echo
BDS
echo
BAMS
echo
BHMS
echo
BUMS
echo
BNYS
echo
BSc (Nursing)
echo
BPT
University :
College :
Date of completion of Degree (Final Year):
(dd/mm/yyyy)
(Probable) Date of Completion of Internship (if applicable):
(Format - dd/mm/yyyy)
UG Marks Details
Phase/Year
Maximum Marks
Marks Obtained
No. of Attempts
First Year
Second Year
Third Year
Fourth Year
Fifth Year
Total
(Total Attempts gets calculated)
Any Other Degree / Diploma :
University :
College :
Date of completion of Degree (Final Year):
(dd/mm/yyyy)
Percentage of Marks Obtained (Final Year) :
Provisional / Permanent Professional Registration No. of qualifying exam:
Name of the state/Central Council where registered of qualifying exam:
Whether debarred from any earlier Post Graduate Entrance Exam ? :
(Select)
No
Yes
Any Criminal case filed against you relating to post graduate entrance exam ? :
(Select)
No
Yes
Fees :
echo
(select)
echo
1000
Online Transaction ID (enter full id) :
Payment Date :
(dd/mm/yyyy)