Application form for JIPMER MD/MS Entrance Examination January 2017 Session
Note: 1. Fields marked with * are mandatory.
2. Fill in the details and click on Submit to proceed.
3. Kindly use Internet Explorer (9 to 11) or Mozilla Firefox (14 to 34) or Google Chrome (20 to 36) to fill in the Application Form.
4. After successful payment you will receive User Name and Password to the registered Mobile number and Email ID.
5. Please read the Prospectus carefully before filling this application.
6. No changes will be entertained, after this form is submitted.
7. No refund will be made under any circumstances for the submitted application.
8. Please keep a printout of the application summary for your future reference.
Personal Details
Note:The details should correspond to entry in any standard document issued by Government/School/College/University.
*Name of the Applicant (First Name) (Middle Name) (Last Name/Initial)
*Son/Daughter of (First Name) (Middle Name) (Last Name/Initial)
Note:The date of birth should correspond to the entry in 10th Standard Marksheet/Certificate.
*Gender Male Female Transgender *Whether OPH Yes No
*Date of Birth (dd/mm/yyyy) *Resident Indian National Yes No
*Overseas Citizen of India Yes No
Candidate's ID Proof & Category details
Note:Enter your ID proof and category Details .
*ID Proof *ID Proof no
*Are you an Indian Candidate Sponsored by Govt (State/Central/Services) [OR] a Foreign National Candidate
Qualification Details
*Are you a Graduate (MBBS degree) from JIPMER Yes  No 
* MBBS Degree Recognized by MCI Yes  No  *Service Candidate Yes  No   
Name of State Medical Council *MCI Registration Number
*Name of college(MBBS) *Name of University(MBBS)
*Aggregate % of Marks (Overall) *Class/Grade
*Date/Expected Date of Completion of Internship Training *Month and Year of passing MBBS
Other Details
*Parent's Educational Background
*Parent's/Gaurdian's Occupation
*Parent's Annual Income
Present Address
*Address Line 1 *Mobile No
Address Line 2 *Confirm Mobile No
Address Line 3 *Email Address
*Confirm Email Address
*Town/City Telephone No.
*Pin code
*Permanent Address Same as Present Address? Yes No
Permanent Address
*Address Line 1 *Mobile No
Address Line 2 *Confirm Mobile No
Address Line 3 *Email Address
*Confirm Email Address
*Town/City Telephone No.
*Pin code
Exam City Preference
Note: The Exam City preference is only indicative and subject to change, Jawaharlal Institute of Postgraduate Medical Education & Research retains the final decision on the same and its allotment. If the Exam Seats are unavailable in above chosen 3 Exam Cities, Nearby exam cities will be considered.
* Preferred Exam City Option 1:
* Preferred Exam City Option 2:
* Preferred Exam City Option 3:
Upload Scanned Copies
 *Please upload scanned copies of your photo,signature here
Note: Application Form cannot be edited once submitted.

I hereby declare that I have carefully read the Prospectus and the Non-Disclosure agreement in Page No.18 of the prospectus. All the particulars stated in this application form are true and correct to the best of my knowledge and belief. If any of these information provided is found false/ incorrect, I shall abide by the actions and decisions taken by the Jawaharlal Institute of Postgraduate Medical Education & Research.

    I Agree
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