Date of Registration………………….
Registration Form for admission to BDS Course
1. Name of Student …………………………………………. 2. Date of Birth ……………………
3. Father’s / Guardian’s Name ……………………………………………………………………..
Address………………………………………………………………………………………………
4. Occupation ………………Designation………………….. 5. Income…………………./Month
6. Telephone No with STD Code (Off) ………………………….. (Res) ………………………….
Mobile No. Self……………………………Father/Guardian……………………………………
7. Marks in qualifying (10+2) Exam: U.P. Board / CBSE / ICSE / Others …………………………
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10+2 Year of Passing …………
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10th
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S.No.
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Subject
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Mark
obtained
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Max
Marks
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Subject
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Mark
obtained
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Max
Marks
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2.
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3.
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4.
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5.
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6.
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Total =
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Total =
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8. Aggregate % age in qualifying exam: ………………9. Medium of Education : Hindi / English
10. Category / Caste: UPGC / UPBC / UPSC / UPST / OTHER STATE
11. If appeared in UPCAT Entrance: R.No. ………………...Rank ………………………………….
12. Whether College Bus Facilities are required: Yes / No. If Yes , from ………………………
13. Whether Hostel Facilities are required: Yes / No
14. Local Guardian’s Name & Add. ………………………………………………………………….
…………………………………………………………………………………………………………
15. Contact No. – (Off) …………………… (Res) …………………… (Cell) ……………………....
Signature of Father / Guardian Signature of Student
For Office Use
Form No. …………. Date of Admission ………………..