VADAMALAYAN
INSTITUTE OF MEDICAL AND
ALLIED HEALTH SCIENCES
Affiliated with THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY
(Institution Code : 444)
#15, Jawahar Road, Chokkikulam, Madurai(625002),Tamil Nadu, India.
Phone : 0452- 2545491, 7708259595.
Email ID:
[email protected]; Website: www.vadamalayan.org
INSTRUCTIONS
1. The requested details are to be filled in BLOCK LETTERS and in the candidate’s own
handwriting neatly and legibly. Affix your
2. Please enclose photo copies of mark sheets & certificates along with this form. latest
3. All Original Certificates should be produce only at the time of admission. passport
size
Courses Offered photograph
here
Code No. Course Name
8001 B.Sc. Accident and Emergency Care Technology Kindly mention any one course code number in
the option
8002 B.Sc. Operation Theatre and Anesthesia Technology
8005 B.Sc. Dialysis Technology
Option :
8006 B.Sc. Cardiac Technology
8008 B.Sc. Physician Assistant
Note : The option you have selected would be given the first preference.
8013 B.Sc. Nuclear Medicine Technology
8023 B.Sc. Radiography and Imaging Technology
Personal Data:
1.Name (As per your certificate)
2. Date of Birth : 3. Sex / Gender 3.1 Marital Status
D D M M Y Y Y Y M F Single Married
(The candidate should have completed 17 Years of age at the time of admission or should complete the age on or before 31st De cember of the year
of admission)
4. Nationality : 5.Religion : 6. Blood Group:
7. Community: Community Certificate No.
8. Father Name :
Father Profession : Annual Income Rs.
9. Mother Name
Mother Profession : Annual Income Rs.
10. Present Address with Pin Code Permanent Address with Pin Code
11. Mobile No.: 12. Landline No.:
13. Email Id (Candidate) :
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14. Qualification Details (with reference of HSC Certificates)
Exam Passed Board School Place State District
Duration Registration No Month & Year of T.C. No T.C.Date School Relieving Date
Passing
14.1.
Subject Tamil English Physics Chemistry Botany Zoology Biology Maths Comp. Sci. Vocational Percentage
Marks
obtained
Total
14.2. Did you reappear for HSC? Yes No If “Yes” Give Details
1st 2nd 3rd
Month & Year of Reappearance
Registration No.
15. Personal identification marks
a._______________________________________________________________________________________________
b._______________________________________________________________________________________________
DECLARATION:
All entries made in the application form are true to the best of my knowledge and belief. I am willing to produce original
certificates on demand at any time. I also undertake that I shall abide by the rules and regulations of Vadamalayan Institute of Medical
& Allied Health Sciences and The Tamil Nadu Dr.M.G.R.Medical University.
Place :
Date :
Signature of the Applicant
UNDERTAKING:
I ..................................................................father/mother/guardian of...................................................................do here by
accept responsibility for good conduct of my son/daughter/ward during the entire period of the course, both inside and outside the
campus.
Place :
Date : Signature of Parent/Guardian
Note: Kindly enclose the following certificate photo copy along with filled application.
1) SSLC, HSC I year and HSC II year mark sheet 3) Community Certificate
2) Transfer Certificate 4) Aadhar Card
Application fee payment Details : 1) Demand Draft / NEFT Transaction details
DD No. / NEFT Reference No
Date
Reference Name
Name of the Bank
FOR OFFICE USE ONLY
Date of interview
SELECTED NOT SELECTED
Candidate has been offered admission in ________________________________________________Course of he batch
____________________________ commencing on _________________________________.
Signature of the Principal with Seal
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