fix passport colour photograph - Era University · colour photograph postgraduate application form...
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Applicant to fix passport size recent colour photograph POSTGRADUATE APPLICATION FORM Session 2020 - 2021 APPLICATION FOR ADMISSION IN FACULTY OF BASIC MEDICAL SCIENCES (M.Sc.) MEDICAL ANATOMY MEDICAL BIOCHEMISTRY MEDICAL PHYSIOLOGY MEDICAL MICROBIOLOGY MEDICAL PHARMACOLOGY M.Sc. FOOD & NUTRITION RADIOLOGICAL IMAGING TECHNIQUES FACULTY OF PARAMEDICAL SCIENCES (M.Sc.) MEDICAL LABORATORY TECHNIQUES OPTOMETRY 1. NAME OF THE APPLICANT : MS./MRS./MR. (IN BLOCK LETTERS) 2. DATE OF BIRTH [ DD ] [ MM ] [YEAR] 3. SEX (✔) MALE FEMALE 4. NATIONALITY 5. DO YOU HAVE ANY PHYSICAL DISABILITIES? (✔) YES NO 6. DO YOU HAVE ANY MEDICAL CONDITION OR LEARNING DISABILITY THAT MAY REQUIRE SPECIAL ATTENTION DURING THE COURSE ? YES NO 7. CATEGORY GENERAL OBC SC/ST OTHER STATE MASTER IN HOSPITAL ADMINISTRATION (M.H.A) DEPARTMENT OF MANAGEMENT FACULTY OF SCIENCE PG DIPLOMA IN GAME DESIGN & DEVELOPMENT PG DIPLOMA IN ANIMATION & MULTIMEDIA PG DIPLOMA IN VFX & ROTOSCOPY PG DIPLOMA IN UI DESIGN & DEVELOPMENT MASTER OF PHYSIOTHERAPY FACULTY OF ALLIED HEALTH SCIENCES MEDICAL SURGICAL FACULTY OF NURSING (M.Sc.) COMMUNITY HEALTH OBSTETRIC & GYNAECOLOGY CHILD HEALTH (PAEDIATRICS) MENTAL HEALTH (PSYCHIATRIC) 8. PERMANENT ADDRESS Transaction ID E U ERA UNIVERSITY Sarfarazganj, Hardoi Road, Lucknow-226003
Transcript of fix passport colour photograph - Era University · colour photograph postgraduate application form...
Applicant to
fix passport
size recent
colour
photograph
POSTGRADUATE APPLICATION FORMSession 2020 - 2021
APPLICATION FOR ADMISSION IN
FACULTY OF BASIC MEDICAL SCIENCES (M.Sc.)
MEDICAL ANATOMY
MEDICAL BIOCHEMISTRY
MEDICAL PHYSIOLOGY
MEDICAL MICROBIOLOGY
MEDICAL PHARMACOLOGY
M.Sc. FOOD & NUTRITION
RADIOLOGICAL IMAGING TECHNIQUES
FACULTY OF PARAMEDICAL SCIENCES (M.Sc.)
MEDICAL LABORATORY TECHNIQUES
OPTOMETRY
1. NAME OF THE APPLICANT : MS./MRS./MR. (IN BLOCK LETTERS)
2. DATE OF BIRTH
[ DD ] [ MM ] [YEAR]
3. SEX (✔)
MALE FEMALE
4. NATIONALITY
5. DO YOU HAVE ANY
PHYSICAL DISABILITIES? (✔)
YES NO
6. DO YOU HAVE ANY MEDICAL CONDITION OR LEARNING DISABILITY THAT MAY REQUIRESPECIAL ATTENTION DURING THE COURSE ?
YES NO
7. CATEGORY GENERAL OBC SC/ST OTHER STATE
MASTER IN HOSPITAL ADMINISTRATION (M.H.A)
DEPARTMENT OF MANAGEMENT
FACULTY OF SCIENCE
PG DIPLOMA IN GAME DESIGN & DEVELOPMENT
PG DIPLOMA IN ANIMATION & MULTIMEDIA
PG DIPLOMA IN VFX & ROTOSCOPY
PG DIPLOMA IN UI DESIGN & DEVELOPMENT
MASTER OF PHYSIOTHERAPY
FACULTY OF ALLIED HEALTH SCIENCES
MEDICAL SURGICAL
FACULTY OF NURSING (M.Sc.)
COMMUNITY HEALTH
OBSTETRIC & GYNAECOLOGY
CHILD HEALTH (PAEDIATRICS)
MENTAL HEALTH (PSYCHIATRIC)
8. PERMANENT ADDRESS
Transaction ID
EU ERA UNIVERSITYSarfarazganj, Hardoi Road, Lucknow-226003
15. FATHER’S NAME
PARENT/GUARDIAN DETAILS
16. MOTHER’S NAME
17. NAME OF GUARDIAN
12. MAILING ADDRESS
CITY
STATE
PIN CODE TELEPHONE
MOBILE
+91
SAME AS PERMANENT ADDRESS
PIN CODE 9. TELEPHONE
10. MOBILE
+91
11. E-MAIL
CITY
STATE
13. HAVE YOU WORKED AT ERA UNIVERSITY IN THE PAST ? YES NO
14. IF YES SPECIFY DURATION FROM ........................................... TO ...........................................
NAME ................................................................................................................................................................................................................
EMPLOYEE ID ........................................................
25. ANY OTHER PROFESSIONAL QUALIFICATION / DIPLOMA
Year ofPassing
Board/University
% ofMarks
Division/Grade
Experience inMonths/ Years
Name of ProfessionalQualification/Diploma
DECLARATION BY THE CANDIDATE
I ....................................................... S/o or D/o ....................................................... declare that the information
furnished by me herein is true and correct. In case any information furnished herein is found to be
incorrect or any document is found to be forged, I agree to forego my claim for admission and abide by
the decision of the University authorities.
I further declare that I have fully read the prospectus furnished with the application form and understood
the contents therein clearly and I hereby undertake to abide by the conditions prescribed therein.
PLACE :
Date : Signature of the candidate
24. EDUCATIONAL QUALIFICATION
Roll No.Year ofPassing
Board/University
Subject Offered
10th Std./High school
SSC/(10+2)/Inter
Examination
Under graduation
Post graduation
% ofMarks
Division/Grade
18. OCCUPATION OF GUARDIAN
21. QUALIFICATION OF GUARDIAN
22. MOBILE OF GUARDIAN
+91
23. EMAIL OF GUARDIAN
20. IF YES SPECIFY DURATION FROM ........................................... TO ...........................................
NAME ................................................................................................................................................................................................................
EMPLOYEE ID ........................................................ RELATION ........................................................
19. HAS YOUR GUARDIAN OR ANY OTHER KNOWN PERSON WORKED AT OR IS WORKING AT ERA UNIVERSITY ?
YES NO
26. LIST OF ENCLOSURE :
POST GRADUATE APPLICANTS ARE INSTRUCTED TO ENCLOSE THE FOLLOWING DETAILS:
Signature of the Candidate
x
The duly filled application should be submitted in person or by post to:
S.no. Particulars
Self Attested copy of SSLC Mark Sheet
Self Attested copy of 10+2 Mark Sheet
Self Attested copy of UG Degree (or) Provisional Certificate
The Admission Cell,
Era University,
Sarfarazganj, Hardoi Road,
Lucknow-226003
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Self Attested ID & Address Proof1
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