Student Verification Form
Note : Kindly use Internet Explorer (version 10 to 11) or Mozilla Firefox (60 to 73) or Google Chrome (70 to 83) to fill in the Admission Form.
Fill in the details and click on Save & Next to proceed. Once Course detail tab is fill and click on Save and Next will not allow back to edit the course details.
Fill in the details of Course Details and Personal Details tab and click on Save & Next, You will get User ID and Password through registered Email iD.
Registered users can Login here.
Fields marked with * are mandatory.
 
Course Details
* Course Alloted
* Course Preference
* Entrance Exam Roll Number
 
Personal Details
* Full Name (Please enter your Full name as per your qualification certificate.)
(First Name) (Middle Name) (Last Name)
* Gender * Date of Birth
* Mobile no * Email id
* Alternate Mobile no/Confirm Mobile No * Alternate Email id/Confirm Email id
* Nationality * Religion
* Community Caste
Mother Tongue Marital Status
Blood Group Marks of Identification
Post Office Name(Note: Post office in your area) Police Station(Note: Police Station in your area)
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 Address Line 2
*Country
*State
*District
*Pincode
*Emergency Contact Number
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.
   
Immunisation Details
* 1.Have you received three doses of Hepatitis B vaccination? Yes No
* 2.Are you Hepatitis B carrier? Yes No
    I Agree
   
Version 14.03.01