ApplicantDetails

APPLICATION FORM TO APPEAR FOR THE ENTRANCE TEST FOR ADMISSION INTO SUPER SPECIALITY
COURSES FOR THE ACADEMIC YEAR 2016-17 AVAILABLE AT THE COLLEGES LOCATED IN AP & TS.

D03

Office Use Only

Application Number : 17030150
Name :
SNIGDHA KOMAKULA
Registration No :
Gender :
Female
Father Name :
K V V S N PRASAD
Applied Course : 17-DMNeurology
Mother's Name :
K SRI DURGA
Date of Birth :
30/09/1988
Country where Last
India
Degree Completed :
State where Last Degree Andhra
Completed :
Pradesh/Telangana
Please paste your
48-16-4/2
recent photo here.
Address :
Nagarjuna nagar
Town/District :
Krishna
State :
ANDHRA PRADESH
Nationality :
Indian
Identification Mark 1 :
A black mole on left cheek
A black mole on back of
Identification Mark 2 :
the neck
Mobile No :
7093012131
Alternate Mobile No :
9866212100
E-Mail :
snig.med@gmail.com
PG Area :
SWI
Social Category : BC-B PH Status :
No
Academic Details :
Sr.

Examination

Study Period
From
07/07/1999
06/07/2000
09/07/2001
08/07/2002
03/07/2003

To
22/04/2000
21/04/2001
23/04/2002
24/04/2003
30/04/2004

College

1
2
3
4
5

6th Class
7th Class
8th Class
9th Class
10th Class

NIRMALA HIGH SCHOOL

NIRMALA HIGH SCHOOL
NIRMALA HIGH SCHOOL
NIRMALA HIGH SCHOOL
NIRMALA HIGH SCHOOL
SRI CHAITANYA CO-OP JUNIOR
MAHILA KALASALA

Intermediate/ 10+2 21/06/2004

20/03/2006

UG Course

01/08/2006

27/03/2012

SIDDHARTHA MEDICAL COLLEGE

PG Degree/
Diploma:
MD
15/07/2013
Specialization:
GENERAL MEDICINE

17/07/2016

SIDDHARTHA MEDICAL COLLEGE

University
BOARD OF SECONDARY EDUCATION
BOARD OF SECONDARY EDUCATION
BOARD OF SECONDARY EDUCATION
BOARD OF SECONDARY EDUCATION
BOARD OF SECONDARY EDUCATION
BOARD OF INTERMEDIATE
EDUCATION
NTR UNIVERSITY OF HEALTH
SCIENCES
NTR UNIVERSITY OF HEALTH
SCIENCES

District
Krishna
Krishna
Krishna
Krishna
Krishna
Krishna
Krishna

Krishna

No of years of study from class 1 to intermediate in AP/TS : 12 Yrs.

PG Details :
PG Degree :

MD
NTR UNIVERSITY OF
HEALTH SCIENCES

University :

Subject :
GENERAL MEDICINE
Medical Council Reg. No
75984
of PG Degree :

Marks Details :
Maximum
Marks
1
PG
400
2
Medicine Marks in MBBS
300
Total Marks :
700
Total Obtained : 404
Sr.

Course

Marks
Obtained
210
194

Percentage
52.50
64.67
Percentage (%) : 57.71

Is studying in super specialty course : N

Course Name:
Year of Passing:
Candidate Status:

NA
NA
Local

College name :

NA

Test Center Details :

Center Choice 1 : Vijayawada

Center Choice 2 : Hyderabad

Center Choice 3 : Visakhapatnam

Payment Details :
Payment Date
10/07/2016

Payment Transaction No
GAXG4597960590

Payment Receipt No
20160710

Amount
5000

Declaration : I hereby solemnly and sincerely affirm that the statements made and information
furnished by me in the online application and in the enclosure submitted are true and
correct. If any information furnished therein is fraudulent, incorrect or untrue, I realize
that my application will be rejected and I will not be allowed either to appear for
Entrance Test or selection / admission. I am able for criminal prosecution. I shall abide
by the decision of the University.
Place : Krishna
Date :

Left Thumb Impression

2016. All copyrights reserved NTRUHS.

Version 11.01.00

Signature of Candidate