APPLICATION FORM FOR BPT
(2021-22)
APPLICATION NO: MMU/BPT/21/245
Campus Details
Campus Course Specialization Whichever Is Applicable
MMDU, MULLANA-AMBALA PHYSIOTHERAPY BPT GENERAL SEAT
Personal Details
Name NIRBHAY KUMAR Email Address [email protected]
Mobile No. +91-9304497718 Blood Group
Date of Birth 27/11/2002 Gender MALE
Marital Status SINGLE Religion HINDU
Are You Physically Challenged NO Nature Of Deformity
Would You Require
Percent Of Deformity
Transportation Facility
Would You Require Hostel
Nationality INDIAN
Accommodation
Category GENERAL State Of Domicile BIHAR
District SIWAN Aadhar Card No. 330524448612
Country Of Residence Passport Number
Country Place Of Issue
Date Of Issue Date Of Expiry
Proof of Identity AADHAR CARD
Parents Details:
Father Details Mother Details
Name LATE BHOLA SINGH SANGITA DEVI
Home Phone
Mobile Number +91-9304497718
Occupation
Designation
Email Address
Annual Income
Address Details:
Is Permanent Address Same As Address For Communication? YES
Correspendence Permanent
Country Name INDIA INDIA
State Name BIHAR BIHAR
District Name SIWAN SIWAN
City Name SIWAN SIWAN
Address Line 1 SIWAN ,MAHARAJGANJ SIWAN ,MAHARAJGANJ
Address Line 2
Pincode 841238 841238
Educational Details
Other
X XII
Qualification
Institute USCD DAV SCHCL MAHARAJGANJ USCD DAV SCHCL MAHARAJGANJ
CENTRAL BOARD OF SECONDARY CENTRAL BOARD OF SECONDARY EDUCATION
Board / Univesity
EDUCATION (CBSE) (CBSE)
Status - PASSED
Year of Passing 2018 2020
Score Type CGPA OUT OF 9 CGPA OUT OF 9
Percentage /CGPA 8.5 9
Marks Obtained In XIIth
Subject Total Marks Obtained Marks Percentage
1. English 100 78 78
2. Physics 100 51 51
3. Biology 100 51 51
4. Chemistry 100 58 58
5. PHYSICAL EDUCATION 100 72 72
6.
Total - 500 310 62
Entrance Test Details
Have you taken any competitive exam? NO
Entrance Name Roll No. Valid up to Score/Percentile Conducted by
How Did You Know About Us?
How Did You Know About Us RELATIVES/FRIENDS Please Specify Details
Declaration
I certify that the information submitted by me in support of this application is true to the best of my knowledge and belief. I understand that
in the event of any information being found false or incorrect, my admission is liable to be rejected/cancelled at any stage of the program. I
undertake to abide by the disciplinary rules and regulations of the institute
Applicant Name NIRBHAY KUMAR
Parent Name LATE BHOLA SINGH
APPLICATION FORM FOR BPT
(2021-22)
APPLICATION NO: MMU/BPT/21/245
Name of Course: PHYSIOTHERAPY Check List
Name: NIRBHAY KUMAR
Father's Name: LATE BHOLA SINGH Mother's Name: SANGITA DEVI
Address: SIWAN ,MAHARAJGANJ,
City: SIWAN State: BIHAR PIN: 841238
Contect No’s:
Student: +91-9304497718 Father/Guardian: +91-9304497718 Mother:
E-Mail: [email protected] Category: SC/BC/ESM/PH : [ ]
DOB: 27/11/2002 Sex(M/F): MALE Nationality: INDIAN
Name of Board/University: CENTRAL BOARD OF SECONDARY EDUCATION (CBSE)
Name of Institute: USCD DAV SCHCL MAHARAJGANJ Year of Passing: 2020
Marks Obtained in 10+2 in:
Physics:51 out of:100 Chemistry:58 out of:100 English:78 out of:100
Biology:51 out of:100 PHYSICAL EDUCATION: 72 Out of: 100
PCM/PCB/PCME/PCBE:
Total Aggregate:310
(Five Subjects) out of:500 Total Percentage: 62
Details of Original Documents/Photocopies to be presented before the Committee for verification: (along with two extra set of
photocopy of that certificates duly attested to be attached with this form.)
th* * *
10 P O 10+2 P O Character Certificate P O
Migration* P O Any Other* P O Adhar Card*
Document Verified by Verified By REG. Branch Candidate Signature
Seat is allotted in ________________________________subject to verification of original documents by the University and deposit of
fee on the day of Counseling failing which allotment of seat will stand cancelled. Admission will be provisional until final
registration by the University.
APPLICATION FORM FOR BPT
(2021-22)
APPLICATION NO: MMU/BPT/21/245
Name of Course: PHYSIOTHERAPY Check List
Name: NIRBHAY KUMAR
Father's Name: LATE BHOLA SINGH Mother's Name: SANGITA DEVI
Address: SIWAN ,MAHARAJGANJ,
City: SIWAN State: BIHAR PIN: 841238
Contect No’s:
Student: +91-9304497718 Father/Guardian: +91-9304497718 Mother:
E-Mail: [email protected] Category: SC/BC/ESM/PH : [ ]
DOB: 27/11/2002 Sex(M/F): MALE Nationality: INDIAN
Name of Board/University: CENTRAL BOARD OF SECONDARY EDUCATION (CBSE)
Name of Institute: USCD DAV SCHCL MAHARAJGANJ Year of Passing: 2020
Marks Obtained in 10+2 in:
Physics:51 out of:100 Chemistry:58 out of:100 English:78 out of:100
Biology:51 out of:100 PHYSICAL EDUCATION: 72 Out of: 100
PCM/PCB/PCME/PCBE:
Total Aggregate:310
(Five Subjects) out of:500 Total Percentage: 62
Details of Original Documents/Photocopies to be presented before the Committee for verification: (along with two extra set of
photocopy of that certificates duly attested to be attached with this form.)
10th* P O 10+2* P O Character Certificate* P O
Migration* P O Any Other* P O Adhar Card*
Document Verified by Verified By REG. Branch Candidate Signature
Seat is allotted in ________________________________subject to verification of original documents by the University and deposit of
fee on the day of Counseling failing which allotment of seat will stand cancelled. Admission will be provisional until final
registration by the University.
APPLICATION FORM FOR BPT
(2021-22)
APPLICATION NO: MMU/BPT/21/245
Transport Details
Would You Require Transportation Facility : Application No. MMU/BPT/21/245
College Bus From (City) Stoppage
Name NIRBHAY KUMAR Father's Name LATE BHOLA SINGH
Mobile No. +91-9304497718 E-mail Address [email protected]
Course/Branch Roll No.
Address:
Is Permanent Address Same As Address For Communication? YES
Correspendence Permanent
Address Line 1 SIWAN ,MAHARAJGANJ SIWAN ,MAHARAJGANJ
Address Line 2
City Name SIWAN SIWAN
District Name SIWAN SIWAN
State Name BIHAR BIHAR
Country Name INDIA INDIA
Pincode 841238 841238
APPLICATION FORM FOR BPT
(2021-22)
APPLICATION NO: MMU/BPT/21/245
Hostel Details:
Would You Require Hostel Accommodation : Application No. MMU/BPT/21/245
Name NIRBHAY KUMAR
Mobile No. +91-9304497718 E-mail Address [email protected]
Category GENERAL Course PHYSIOTHERAPY
Institute Name Class
Roll No. Admission Rank
Hostel No. Room No.
Session Fee (Due)
Amount (Received)
Parents Details:
Father Details Mother Details
Name LATE BHOLA SINGH SANGITA DEVI
Mobile No +91-9304497718
Email
Occupation
Office Address
Address:
Is Permanent Address Same As Address For Communication? YES
Correspendence Permanent
Address Line 1 SIWAN ,MAHARAJGANJ SIWAN ,MAHARAJGANJ
Address Line 2
City Name SIWAN SIWAN
District Name SIWAN SIWAN
State Name BIHAR BIHAR
Country Name INDIA INDIA
Pincode 841238 841238
Hostel Rules:
1.No student shall keep any unauthorized person in his/her room.
2.In the event of any mischief/foul play or accident etc., the warden will be authorized to break open the room for investigations.
3.Whenever, a student leaves the station or remains outside the hostel for the night, he/she should obtain prior permission of the warden and
enter the same in the register kept in the hostel office.
4.No student is permitted to entertain any student of this college, who stands expelled from the college or the hostel, as guest on any
ground.
5.No female visitor is allowed in boys’ hostels and male visitors in girls’ hostels except in the office with the written permission of the
respective wardens.
6.Students are forbidden to utilize hostel servants for any private work or as private servants.
7.No student will argue abuse or misbehave with the mess contractor/staff. Complaint, if any, should be brought to the notice of the warden
immediately.
8.All the students shall, at all times, conduct themselves in a disciplined manner inside the hostel. They should not do anything which may
disturb others at study or at work in the hostel.
9.The following are strictly forbidden in the hostel:
a.Possession or use of alcoholic beverages.
b.Possession or use of addictive or hallucinogenic drugs.
c.Possession or use of offensive arms or any lethal weapon.
d.Playing cards.
e.Arranging of any private party and cooking private food.
10. The father/mother only are allowed to visit their ward in hostel any time. A relative can meet during day time only if the parents have
supplied the complete information and photo of the concerned person under their signature and authority. The name of such relative should
indicate the exact relationship with the student, if desired by parents to be permitted to see their ward, and should be got approved from the
principal in advance.
11.Parents must provide the address of the relative whom their ward can visit in holidays.
12.The residents in the girls hostel will be treated absent in case they do not mark their evening roll call in time, i.e., up to 07:30 p.m. (in
summer) and 06:30 pm (in winter). Remaining out beyond prescribed time limit without permission is likely to invite expulsion from the
hostel/University without any prior notice.
13.Student shall be responsible for all the costly items like, laptop, mobile and other electronic gadgets in his/her possession.
14.Strict disciplinary action will be taken against students found guilty of any personal violence or abutment thereof. A student should not
take law in his/her own hands but should report his/her grievances, if any to the warden.
15.Ragging is strictly prohibited and is a punishable offence; which can lead to rustication or expulsion from the University and ragging
include causing willful injury or threat of injury, physical or mental willfully degrading or humiliating a fellow student, whereby he/she suffers
distress of mind or spirit.
16.The student should take the possession of the room after checking all the fixtures and furniture. Further, he/she should handover all the
items in the same working condition at the time of leaving the hostel.
I/we have read the above rules/regulations of the hostel and undertake to abide by the same. In case, I/we are found to violate any
rule/regulation, the University is free to take any disciplinary action.
