Admissions to 5 Year BS-MS Dual Degree Programme 2014

Admission Form
1.

Application Number:

2.

Stream (KVPY, JEE Advanced, SCB):

3.

Category (GE, OBC, SC, ST):

4.

PD (Yes / No):

5.

Applicants Name:

6.

Date of Birth:

7.

Fathers Name:

8.

Mothers Name:

9.

Address for Communication:

Paste your recent

passport-size
photograph here

Residence Phone:
Mobile:
Email:

10.

I hereby declare that the particulars stated above are true to the best of my knowledge and
belief. In the event of suppression or distortion of any fact, I understand that my admission/
degree acquired is liable for cancellation. I also understand that the decision of the Joint
Admissions Committee regarding my admission to Indian Institute of Science Education and
Research (IISER) Bhopal / Kolkata / Mohali / Pune / Thiruvananthapuram is final, and I
shall abide by the rules and norms and the discipline of the Institute where I join.

Signature of the Candidate

Place:
Date:

Signature of the Parent / Guardian

Enclosures Check List

Copies of Class 10 (High School) certificate and mark sheet
Proof of date of birth (if not covered in item number 1 mentioned above)
Copies of 10+2 mark sheet and certificate
Copy of JEE (Advanced) Admit Card / KVPY Selection Letter / Eligibility Note from the School
Board for DST Inspire Fellowship (if applicable)
5. SC/ST/OBC/PD Category Certificate, if applicable and as mentioned in the Offer Letter
6. Medical Examination Report Form
7. Bank Draft for Admission Fee or Proof of Admission Fee Payment to the bank, as
mentioned in the Offer Letter.
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