KSSPCMA Application for Admission To B.Pharm/Pharm.D 2024-25

Course applied for *
(Each application shall be used for one course only)

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Admission Quota*

Name of the College*

Name in Block Letters*

Sex*

Male

Female

Date of Birth*

Age as on 31-12-2024*

Name of Father*

Name of Mother*

Religion & Community*

Permanent Address*

Address for Communication*

Phone Number*

Mobile No*

Email Address *

Details of Qualifying Examination

H.S.E or Equivalent, specify*

University / Board*

Marks Obtained

Subjects	Maximum Marks	Marks Secured	Percentage	No. of Chances
Physics
Chemistry
Mathematics
Biology
Total Marks

Annual Income of the Family

If the candidate is claming any reservation or other benefits, furnish details

Application Fee Details

ONLINE APPLICATION FORM FEE SHALL BE REMITTED(ONLINE PAYMENT OF RS.1000/- PER COURSE) IN ASSOCIATION BANK
ACCOUNT - KSSBCMA
ACCOUNT NUMBER - 0552053000001348
IFSC - SIBL0000552
BRANCH NAME - SOUTH INDIAN BANK, NORTH CHALAKUDY BRANCH, THRISSUR

Transaction ID*

Date

Bank*

I, .................................... do hereby declare that the particulars given in the application are true to the best of my knowledge and belief. If any of the particulars given by me in this application is proved fraudulent at any later stage of admission, I shall be liable for disciplinary action and my admission shall become null and void. I shall produce the originals of the certificates at the time of interview.I carefully read the prospectus thoroughly and I am ready to abide the terms and conditions mentioned in the Prospectus.

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Name & Signature of the Candidate