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Colour Photo

INSTRUCTIONS

1. Fill the form completely & carefully with providing your recent color photograph (Passport Size).
2. Take a print-out of the form after submitting.
3. Put your signature in respective columns.
4. Send the completed application form along with application fee of Rs. 200/- in the form of a
    Demand Draft in favour of "BHABHA CLASSES" payable at Kanpur.
5. Send the form by Speed Post to: "BHABHA CLASSES FOR MEDICAL" C/o 607 C-Block, Panki,
    Kanpur (U.P.) - 208020

Technical Support for Contact us:- (+91) 9616037649



       
Personal Details:Provide your Personal details.
 
                         
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Mr.   Ms.
    Rs.
Contact Details:Provide your Contact details.

   
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Academic Details:Provide your Qualification details.
Examination Name of School Place of
School
Passed/Appearing Year of
Passed/Appearing
Aggregate
% Marks
High School (X) %
Intermediate (XII) %
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Security Code:Provide the disaplayed security code (Click the code to re-generate).

DECLARATION

I hereby declare that all the information provided in this form are true to the best of my knowledge & belief. Any violation found will lead to the cancellation of my admission and I give my absolute consent to be solely agreed with the decision of institution authorities. Further, if admitted, I promise to abide by the rules and norms of discipline of the institute. In case of any dispute, the court in Kanpur shall alone have the exclusive jurisdiction whatsoever.
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