KARNATAKA RELIGIOUS & LINGUISTIC MINORITY
PROFESSIONAL COLLEGES ASSOCIATION (KRLMPCA) (Regd.)
Flat No. 143, 'SURYAMUKHI', Garden Apartments,
#21,Vittal Mallya Road, Bangalore - 560 001. ph: 080-4112 1233 Fax: 080-4112 1266
Email: info@kmca.info; admissions@kmca.info; kmca@airtelmail.in
Website: www.kmca.info
APPLICATION FOR ADMISSIONS TO MBBS/BDS/BE COURSES
FOR THE YEAR 2008-09
Application No.:   27419
(Incomplete applications are liable for rejection.)
[FILLED APPLICATIONS SHOULD BE SENT TO THE ASSOCIATION OFFICE ONLY TO THE ADDRESS INDICATED ON THE TOP OF THE APPLICATION FORM ADDRESSED TO CHIEF EXAMINER.]
1. PERSONAL DETAILS:  
a. The Course applied : MBBS/BDS/BE
b. Name of the candidate
   (In BLOCK LETTERS)		 : ______________________________
c. Date of Birth : __________________________________
d. ADDRESS FOR CORRESPONDENCE
   (In BLOCK LETTERS)		 : ______________________________
    ______________________________
    ______________________________
e. Telephone No : __________________________________
f. Cell No : __________________________________
g. Email ID : __________________________________
h. Nationality : __________________________________
i. Sex : Male    Female  
j. Whether belong to Karnataka or non – Karnataka (if non-karnataka please Specify State) : ______________________________
k. i) Name of the Father/Guardian : ______________________________
   ii) Occupation : ______________________________
l. i) Name of the Mother : ______________________________
   ii) Occupation : ______________________________
m.Annual Income of the parents from all the sources : ______________________________
2. Whether Belongs to : Religion : Muslim / Sikh / Jain
  Linguistic : Tulu/Telugu/Tamil/Kodava/Sindhi
  General ___________________________
3. Centre you wish to appear for UG ET     2008 (Please choose any one centre) BANGALAORE / MANGALORE / RAICHUR / GULBARGA / BELGAUM / DELHI / AHMEDABAD
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4. ACADEMIC DETAILS:
a. X Std / SSLC / SSC or equivalent
Registration No Name & Address Of the School Year of Passing
b. XII Std / PU / 10+2 or equivalent
Registration No Name & Address Of the School Year of Passing
c. Marks Obtained in PU or Equivalent:
SUBJECTS MAX.MARKS MARKS OBTAINED PERCENTAGE
PHYSICS
CHEMISTRY
MATHS
BIOLOGY
ENGLISH
(Please note if the results are not declared at the time of submission of application you may indicate “RESULTS ARE AWAITED)
5.Remittance Details
(i). DD No.  __________________      (b)Date  __________________(c)Bank_____________________
for Rs.1000.00 drawn in favour of "KRLMPCA,Bangalore" Payable at Bangalore is enclosed

DECLARATION

I declare that the above information is true and correct to the best of my knowledge and belief. In case if any of the above information is found to be false or incorrect. I shall forfeit the claim to be considered for a seat in Professional College and if a seat is already given, forfeit the same. In such an event, I and or my parent / guardian will also be liable for such civil / criminal action as the management may take against me / us for submitting false information.


LEGAL JURISDICTION: BANGALORE - KARNATAKA
 

(Signature of the Father / Guardian) (Signature of the Candidate)
Date:
Place: