Bareilly Institute of paramedical!

Registration Fees & Courses	Non Refundable Fees	Account Holder Name:-	BAREILLY INSTITUTE OF PARA MEDICAL SCIENCES
1- Diploma Courses	5000/=	IFSC CODE	SBIN0016725
2-Degree Courses	10000/=	ACCOUNT NO.	34171938437
		Branch Name	MAHANAGAR BAREILLY

APPLICANT FULL NAME *

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MOTHER NAME *

FATHER NAME*

DATE OF BIRTH *

PERMANANT ADDRESS *

CITY*

PIN CODE *

STATE *

CORRESPONDENCE ADDRESS*

Same As Above

CITY *

PIN CODE*

STATE *

E-MAIL ID *

PASSWORD*

CONFIRM PASSWORD*

MOBILE NO *

ALTERNATE MOBILE NO (IF ANY )

LAST EXAM PASSED (WITH YEAR)

YEAR

COLLEGE LAST ATTENDED

AGE AS ON Ist July OF YEAR OF ADMISSION

QUALIFICATION

#	EXAMINATION *	UNIVERSITY / BOARD *	YEAR OF PASSING*	DIVISION	SUBJECTS
1
2
3
4
5
6

APPLIED FOR (Tick any one )*

DIPLOMA IN PHYSIOTHERAPY		CODE-P-01
DIPLOMA IN OPTOMETRY		CODE-O-02
BACHELOR IN OPTOMETRY		CODE-O-03

MARKS OBTAINED IN THE INTERMEDIATE(10+2) EXAMINATION *

Select Your Group? Bio Math
ENGLISH		PHYSICS
BIOLOGY		MATHEMATICS
CHEMISTRY		HINDI
TOTAL		PERCENTAGE

ADMISSION FEES PAYMENT DETAILS

BANK DRAFT NO		DATE
NAME OF BANK		BRANCH

DECLARATION : All the terms and condition has been accepted by me. And all the information given by me infront of you are absolutely correct and true in my knowledge .*

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