No Chairman - Tel.

: 91 - 080 - 2546 1357

Principal - Tel./Fax: 91 - 080 - 2546 0747
Off.: Tel./Fax: 91 - 080 - 2547 6496
Off.: Tel.: 91 - 080 - 2546 3097
email: principalmradc@gmail.com
website: www.mradc.ac.in

Chairman

Founded by: ANANDA SOCIAL & EDUCATIONAL TRUST. (Regd.) Bangalore

(Affiliated to the Rajiv Gandhi University of Health Sciences) Passport size
photo to be
affixed
(Recognized by Dental Council of India)

Application for admission to the First Year B.D.S Course for the Year 2013 - 14

1. Name of the Candidate in Block Letters

Comed K Rank No.:

2. Nationality Sex and Religion:

& Caste (Sub-Caste)

3. Mother Tongue

4. Whether the Candidate belongs to

SC / ST or other Backward Classes
(Valid documents to be produced)

5. Name of the Parent / Guardian

6. Age & Date of Birth (in words & figures)

(SSLC / Matriculation Certificate to be produced)

7. Postal Address:
Present:

Permanent:

Telephone No.:
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8. Occupation of Parent / Guardian with

Annual Income (Income Certificate to be produced)

9. Academic Qualifications:

Higher Examination Passed - 10 + 2 / PUC

Marks obtained in
Physics

Chemistry

Biology

Aggregate Percentage

10. Previous Institution attended:

Subject studied

Class & Roll No.:

11. Attested copies of following

Certificates to be enclosed:

(A) Pass Certificate of qualifying Exam

(B) Marks list of the qualifying Exam

(C) Migration Certificate

(D) Transfer Certificate

(E) Eligibility Certificate

(F) Medical Certificate

12. Extra-curricular activities

(Separate sheet may be enclosed, if need be)

13. Other Information, if any

14. Place | Date: Signature of the Candidate

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DECLARATION OF THE CANDIDATE

I wish to apply for the admission to M. R. A. Dental College and declare that I have filed this form myself and to the best of my

knowledge and belief, the above particulars are true.

I have gone through the instructions for reservation and admission carefully and undertake to abide by the conditions. I further

agree, if admitted, to abide to the rules and regulations at present in force or that may here after be made by the management. I

undertake that as long as I am a student of the College, I will do nothing unworthy of a student of the college either inside or

outside or I will not engineer or participate or indulge in any unlawful activity or do anything against the interest of the institution

do anything that will interfere with its orderly working and discipline. I am aware that the management has full authority to expel

me for indiscipline, misbehavior or indulging in ragging and any such activities maintained which are detrimental to the fair

name of the Institution.

Place: Candidate’s Signature

Date:

DECLARATION OF THE PARENT / GUARDIAN

I hereby declare that I know the financial obligation and I can afford to pay all the costs and undertake to pay the tuition and

other fees payable to the Institution under the rules framed from time to time by the Management of the College. I also declare

that I will not question the disciplinary action taken against my ward for any indiscipline such as ragging, misbehavior and any

such actions which are against the interest of the College and the Management or any such actions which are against the

interest og the College.

Place: Signature of the Parent / Guardian

Date:

Note:
Send Rs. 5000/- Demand Draft favoring “The Principal, MRADC” payable at Bangalore, along with the filled in application.
Application form without demand draft attached would not be considered
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FOR OFFICE USE ONLY

The applicant ___________________________________________________ has been given provisional

Admission to ____________________ class, for the academic year ______________ his / her statement of

marks and other documents relating to Income and Caste are verified and found correct.

Fee paid vide Receipt No.: ________________________ Date: ___________________

Registration No.:

Checked

Clerk Accountant Superintendent

Principal
Date: Mathrusri Ramabai Ambedkar Dental College & Hospital

Note:
Send Rs. 5000/- Demand Draft favoring “The Principal, MRADC” payable at Bangalore, along with the filled in
application.
Application form without demand draft attached would not be considered