MOULANA COLLEGE OF PHARMACY

NEAR RAILWAY STATION
PO: ANGADIPPURAM, PIN : 679321.
MALAPPURAM DISTRICT KERALA

APPLICATION FOR ADMISSION TO D.Pharm 2023-24

Course applied for *

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Application No.*

Admission Quota*

Name of the College*

Name of Student* (In Block Letters as per SSLC Certificate)

Sex*

Male

Female

Date of Birth*

Age as on 31-12-2023*

Nationality*

Name of Father*

Name of Mother*

Religion & Community*

Permanent Address*

Address for Communication*

Phone Number*

Mobile No*

Email Address *

Details of Qualifying Examination Passed

H.S.E or Equivalent, specify*

Name of the Board / University*

Reg. No., Year of Exam and Month*

Details of Marks Obtained :

Exam Results

Subjects	Maximum Marks	Marks Secured	Percentage of Marks	No. of Chances
Physics
Chemistry
Mathematics
Biology
Total Marks

Annual Income of the Family

If the candidate is claiming any reservation or other benefits, furnish details.

Application Fee Details.

Transaction ID or Demand Draft No (DD):*

Date

Bank*

Amount*

I, .................................... do hereby declare that the particulars given in the application are true to the best of my knowledge and belief. If any of the particulars given by me in this application is proved fraudulent at any later stage of admission, I shall be liable for disciplinary action and my admission shall become null and void. I shall produce the originals of the certificates at the time of interview. I, carefully read the prospectus thoroughly and I am ready to abide by the terms and conditions mentioned in the Prospectus

Date

Place*

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Name & Signature of the Candidate