Personal Information

Name (Block Letter):
Date of Birth:	[Date Format : yyyy-mm-dd]
Gender:	Male Female
Photo:
Permanent Address:
Temporary Address:
Telephone No:
Mobile Number:
Email Address:
Name of Guardian/Father:

Academic Background

I.Sc.

10+2

CBSE

Others

Appeared College or School Name:

Percentage Obtained:

(10+2/CBSE)

(S.L.C.)

Program of Enrollment

MBBS

B.Sc. Nursing

Others

Do you intend to Study in Self-Finance Scheme?

Yes

No

How did you know about Orbit MBBS?

Newspaper

TV

Hording

Radio

Teachers

Friends/Relatives

Internet

Others

Do you want to take Free Hostel Facility?

Yes	No
Please Expain: