Name of the Applicant(as per SSLC/10th marks card) :
Mother's Name :
Father's Name :
Date of Birth :	(dd/mm/yyyy)
Gender :
Place of Birth :
Place of Birth - District :
Place of Birth - State :
Nationality :
Permanent Address with Pin Code:
Address for Communication with Pin Code :
e-mail :
Phone :
Mobile :
Category:
Do you claim reservation under Hyderabad Karnataka Quota (371 J)?:
Religion:
Caste:
Sub Caste:
Bachelor Degree :
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.:
Name of the state/Central Council where registered :
Whether debarred from any earlier Post Graduate Entrance Exam ? :
Any Criminal case filed against you relating to post graduate entrance exam ? :
Fees :
DD Number :
DD Drawee Bank and Branch :
DD Date :	(dd/mm/yyyy)

INSERVICE    DETAILS

Are You an Inservice Candidate? :
Department :
Present place of working :
Date of Entry into Service :	(dd/mm/yyyy)
Whether Probationary Period declared?:
Probationary Period Declared Date :	(dd/mm/yyyy)
Have you undergone any PG Course ? :
Speciality in which PG Degree / Diploma done / Undergoing :
Whether any departmental enquiry is pending against you? :
Any departmental disciplinary action taken against you ? :
Whether under unauthorised absence? :