SANJIVNI PARAMEDICAL SCIENCE INSTITUTE

Name of Candidate :

Candidate Photo

Father’s / Husband’s

Mother’s Name :

Guardian’s Name :

Father’s/ Guardian’s Occupation :

Occupation Address :

Occupation phone no. :

Date of Birth :

Place of Birth :

Nationality :

Current Mailing Address :

Tel. No. :

Mobile No. :

E-mail Address :

Course to which Admission is sought for (mention in order of preference)

X-Ray TECHNICIAN

CT SCAN TECHNICIAN

MRI SCAN TECHNICIAN

DIALYSIS TECHNOLOGY

CATH LAB TECHNOLOGY

DIPLOMA IN PRACTICAL NURSING

S.S.C or High School Marksheet

H.S.C or Intermediate

Diploma/Degree