To be filled up and submitted for counselling and Admission Sl. No.…………

GIRIJANANDA CHOWDHURY INSTITUTE OF PHARMACEUTICAL SCIENCE-TEZPUR

(An Institute established under PPP model by Shrimanta Shankar Academy and Govt. of Assam)

1. Name of the applicant : in full (in block letters)

2. Sex (M/F) :

3. Date of Birth :

4. Father’s Name :

5. Mother’s Name :

6. Father’s Occupation :

7. Mother’s Occupation :

8. Family Income :

9. Postal Address :

10. Permanent Address :

11. Parent/Guardian’s Contact Details:

STD Code: Phone No:

Mobile No:

E-mail ID:

APPLICATION FORM

Admission Opted for: GIPS-Guwahati/GIPS-Tezpur self-sponsored/ GIPS-Tezpur Govt. quota

Admission sought in: D. Pharm/B. Pharm/B. Pharm (Practice)/M. Pharm/PhD.

Dekargaon, Tezpur, Sonitpur-784501

Azara, Hatkhowapara, N.H.-37, Guwahati- 781017

GIRIJANANDA CHOWDHURY INSTITUTE OF PHARMACEUTICAL SCIENCE (GIPS)

(A unit of Shrimanta Shankar Academy)

(SESSION-2021-2022)

12. Student's Contact Details:

Mobile No:

E-mail ID:

13. Nationality :

14. Religion :

15. Caste/ Category: Gen/SC/ST/OBC/MOBC/Others:

16. Details of Examination Passed :

Name of

the Exam

Name of Board/

University

Year of

Passing

Reg. No.

&

Roll No.

Total

Marks

Prescribed

Total

Marks

Obtained

% of

Marks

Obtained

HSLC

HS.

(10+2)

D. Pharm

B. Pharm*

M. Pharm#

GPAT*

*Applicable for only M. Pharm Candidates

#Applicable for only PhD Candidates

17. Details of marks obtained in H.S./10+2 or Equivalent (Sc.) (only for D. Pharm & B. Pharm)

Exam Marks secured in % of marks in aggregate of

Phys. Chem. Math. Bio. PCM PCB

HS/ 10+2 or

Equivalent (Sc.)

18. Proficiency in Co-curricular activities:

19. Preference of Branch (mention 1, 2, 3 in the box) (For M. Pharm Candidates Only)

Transaction No:

Date of Transaction:

Pharmaceutics Pharmaceutical Chemistry Pharmacology

20. Payment Details: Cash/Online: