To
The Director
Dr. Maity Educational & Medical Research Institute Pvt. Ltd.
515 / 1, Lake Gardens, Kolkata - 45
Sir Madam
I am interested to get admission in your institution for MOCK TESTS for WBJEE MEDICAL 2011.
My C.V. / Bio - data and other relevant particulars are given below for your kind perusal. Hope you will consider my candidature and oblige.
Date -
( FILL IN BLOCK LETTERS)
1. Name of the candidate :
2. Communication Address :
Your photo in JPEG format
e-mail iD : Pin code :
Land Mark ( School / Club / etc) :
Communication Phone No - (Must be given) (a) : (b) :
3 (a) Date of birth:
(b) Sex:
(c) Category - Gen / SC / ST / PH / OBC:
4. Father‚s / Guardian‚ name:
5. Father‚s / Guardian‚ occupation and designation (If any):
6. Receipt Image ( in JPEG ) :
7. Language to be opted (Put √mark) : English / Bengali
8. Name of the Institution last attented:
9 (a) % of marks obtained in Madhyamik or eqvt.:
(b) % of marks obtained in HS or eqvt.:
10 (a) Obtained Rank in (i) JEM - 2010 .:
(ii) AIPMT - 2010 (a) Prelim : (b) Final: (iii)others:
11 Application FORM NO. of (i) WBJEE - 2011: AIPMT - 2011:
Declaration
We declare that the information furnished are true to the best of our knowledge & belief. We have no objection, if candidate‚s name & photograph are used fo publicity in media. I will send a photocopy of admit card of the all the medical entrance examinations appearing before the final examination.
N.B. : Without Xerox copy of HS Marksheet , Communication Phone Number & Photograph of student the ADMISSION will not be granted.