INSTRUCTIONS. Pharmacy Council of India (PCI) & Kerala University of Health Sciences (KUHS) from time to time.

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1 INSTRUCTIONS 1. All the columns in the application form must be filled up by the candidate in block letters in black ball point pen. 2. The candidate should submit the original documents at the time of admission. 3. All admissions are provisional and subject to rules and regulations of Pharmacy Council of India (PCI) & Kerala University of Health Sciences (KUHS) from time to time. 4. The admission of any candidate, even if made, will be cancelled if such admission is found to be made contrary to the referred rules and regulations at any time. In such cases, the candidate shall not have any claim whatsoever in any manner. 5. Fee once paid shall not be refunded. 6. Enclose the following original and attested copies of certificates and mark the Check list Column 7. Rs.200/- to be paid as application fee at the time of submission. CHECK LIST 1. SSLC mark sheet with two attested copies 2. Mark sheet of qualifying examinations with two attested copies 3. Transfer certificate with two attested copies 4. Selection memo/allotment memo 5. Conduct certificate with two attested copies 6. Physical Fitness Certificate 7. Caste Certificate ( Whether SC/ST/OBC) 8. Eligibility Certificate from KUHS 9. Migration Certificate (Applicable for students from outside the state of Kerala) 10.6 passport size photographs- (2 with Name And date of birth of the candidate and 4 normal passport size photo) Signature of admission officer Signature of candidate

2 Cost of Application Form-Rs.200/- Application No: APPLICATION FORM FOR ADMISSION INTO B.PHARM/PHARM.D COURSE K.T.N. COLLEGE OF PHARMACY Chalavara (P.O), Ottapalam (Tal), Palakkad (Dt), Kerala State (Approved by AICTE, PCI & affiliated to Kerala University of Health Sciences) Phone No: (Off) Fax: Website: (Read prospectus of the College carefully before filling up the form) TO BE FILLED IN ONLY BY OFFICE ADMISSION NO DATE OF ADMISSION ELIGIBLE YES NO AFFIX RECENT PASSPORT SIZE PHOTOGRAPH DULY ATTESTED ON FRONT SIDE CONFIRMED / WAITING LIST No: TO BE FILLED IN BY CANDIDATE IN OWN HANDWRITING (WRITE IN CAPITAL LETTER) 1. Name of the applicant in full: (as recorded in the SSLC or any equivalent exam) 2. Date of birth: (as recorded in the SSLC or any equivalent exam) D D M M Y Y Y Y 3. Age : 4. Gender: Male Female

3 5. Blood group: 6. Marital Status: Married single 7. Nationality: Religion: Hindu / Christian / Islam / Others 8. Caste : Whether SC/ST/OBC 9. Name of the father: 10. Name of the mother: 11. Father s occupation and annual income: 12. Guardian s name: (In case father or mother is not guardian) 13. Permanent address: House Name Street Post District Residence no: ID: PINCODE Mobile no Father Candidate 14. Address for Communication with Pin code: House Name

4 Street Post District Residence no: PIN Mob. ID: 15. Details of qualifying examinations: Name of the examination Name of the school/ Month & Year of Regd. No. board passing Subjects Physics Max. Marks Secured Percentage of mark s Remarks Chemistry Biology Computer Applications Mathematics 16. Institution Last Studied: I s/o/ d/o... do hereby declare that the particulars furnished above are true and correct to the best of my knowledge Place: Date: Signature of the Parent/Guardian Signature of the Candidate Signature of the Principal

5 ANNEXURE XII UNDERTAKING FROM THE STUDENTS AS PER THE PROVISIONS OF ANTI-RAGGING VERDICT BY THE HON BLE SUPREME COURT OF INDIA [See Clause 14.3] I, Mr. /Ms...., Application No Course:.student of.... do hereby undertake on this day Month Year.,the following with respect to above subject and Office Order No: 1) That I have read and understood the directives of the Hon ble Supreme Court of India on anti-ragging and the measures proposed to be taken in the above references. 2) That I understand the meaning of Ragging and know that the ragging in any form is a punishable offence and the me is banned by the Court of Law. 3) That I have not been found or charged for my involvement in any kind of ragging in the past. However, I undertake to face disciplinary action/legal proceedings including expulsion from the Institute if the above statement is found to be untrue or the facts are concealed, at any stage in future. 4) That I shall not resort to ragging in any form at any place and shall abide by the rules/laws prescribed by the Courts, Govt. of India and Institute authorities for the purpose from time to time I hereby fully endorse the undertaking made by my child/ward... Signature of Student Signature of Mother/Father and or Guardian Witness :.. Witness :..

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