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Course Details Personal Details Qualification Details Immunisation Details Course Details * Course Alloted ---Select--- * Course Preference ---Select--- *INI Rank * Entrance Exam Roll Number * INI Exam Roll Number * NEET Roll Number * NEET Score (Out of 720) * Health Care Professional Number Yes No * Enter 14 Digit HCP Number * Is Aadhaar No. Linked? ---Select--- Aadhar not linked with mobile number *Health Care Professional ID MBBS * Allotted Campus JIPMER Puducherry JIPMER Karaikal Personal Details * Full Name (Please enter your Full name as per your qualification certificate.) * Gender ---Select--- * Date of Birth * Mobile no * Email id * Confirm Mobile no * Confirm Email id * Nationality ---Select--- * Religion ---Select--- Hindu Muslim Christian Sikh Parsi Others * Please Specify Other Religion * Caste State ---Select--- Andaman and Nicobar Island Andhra Pradesh Arunachal Pradesh Assam Bihar Chandigarh Chhattisgarh Dadra and Nagar Haveli Dadra and Nagar Haveli And Daman and Diu Daman and Diu Delhi Goa Gujarat Haryana Himachal Pradesh Jammu and Kashmir Jharkhand Karnataka Kerala Ladakh Lakshadweep Madhya Pradesh Maharashtra Manipur Meghalaya Mizoram Nagaland Odisha Other Territory PAN India Puducherry Punjab Rajasthan Sikkim Tamil Nadu Telangana Tripura Uttar Pradesh Uttarakhand West Bengal Others * Category ---Select--- *Caste *Mother Tongue *Marital Status ---Select--- Married Unmarried Widow *Blood Group ---Select--- *Marks of Identification *Post Office Name(Note: Post office in your area) *Police Station(Note: Police Station in your area) Please Specify Blood Group Valid ID Proof Details *Passport No *Date of Issue Parents and Guardian Details Father's Details * Name Late(Select checkbox if Father is late) * Occupation *Income * Mobile No. Email Address Mother's Details * Name Late(Select checkbox if Mother is late) * Occupation *Income * Mobile No. Email Address Guardian's Details *Guardian Name *Guardian Occupation *Gaurdian Mobile No. *Guardian Email Address Address for Communication * Are you Domicile of Puducherry UT ? Yes No * Jipmer Hostel Required? Yes No *Address Line 1(Door No & Street Name) *Address Line 2(Locality / Village Name) Address Line 3*(Mandal / Taluk) *Country ---Select--- *State ---Select--- *District ---Select--- *Pincode *Emergency Contact Number * Other District Guardian Details If in Puducherry Local Guardian Name Occupation of the Guardian Guardian's Mobile Number Guardian's Email ID   Upload Your Photo and Signature   * Click here to upload your photo and signature. 12th/Equivalent Qualification Details *Qualifying exam passed with month and year ---Select--- (Month) ---Select--- (Year) *Certificate no. * Name of the School / Juniour college of Study * Name of the Board/ University UG Qualification Details * Name of the UG Degree * UG Percentage * Date of passing UG Examination ---Select--- (Month) ---Select--- (Year) Certificate No * Name Of the College/ University * Name and Address of the College /University * Medical Council Registration Number * Name of Medical Council ---Select--- * Please Specify Name of Medical Council PG Qualification Details * Name of the PG Degree * PG Percentage * Date of passing PG Examination ---Select--- (Month) ---Select--- (Year) Certificate No * Name Of the College/ University * Name and Address of the College /University Immunisation Details * 1.Have you received three doses of Hepatitis B vaccination? Yes No * 2.Are you Hepatitis B carrier? Yes No * When was the last vaccine dose received? ---Select--- (Month) ---Select--- (Year) * Have you checked your anti-HBS titres? Yes No Upload the latest titre report and (bring the latest titre report) here     I Agree
Version 15.01.01