All India Institute of Medical Science

Ansal Nagar, New Delhi - 110608 Entrance Examination - 2013

Registration Slip - AIIMS-PG[MD/MS/MCH(6YR)] JULY 2013 SESSION

1.) Application No.
2) Application Date 3) Course Applied 4) Applicant's Name 5) Date of Birth 6) Father's Name 7) Mother's Name 8) Gender 9) Applied Under 10) Category 1631011786 25 Mar 2013 MD/MS/M.Ch. SOMISETTY HGOUTAMRAJU 20 Feb 1988 S.SREEDHAR S. PADMA Male Neither of these General 18.a) State/Country 18.b) Pin Code 19) Phone No. 20) Mobile No. 21) Fax No., if any 22) Email id 23) Payment Details 23.a) Mode of Payment 23.b) Payment Type Chennai 02 - Delhi 23.c) Payment Date 23.d) Amount 23.e) Branch Code MBBS Foreign Degree china soochow university No N/A 23.f) Journal Number 24) Academic Details 24.a) Maximum Marks 24.b) Marks Obtained 24.c) Percentage 25.) ExamMode 4600 3680.00 80.00 Online (Computer Based Test) Through Debit/Credit Card Registration 26 Mar 2013 1000 17) Correspondence Address 17.a) State/Country 17.b) Pin Code 18) Permanent Address h.no 6-61 near moosa masjid,nagar kurnool, Mehboobnagar Andhra Pradesh 509209 h,no 6-61 near moosa masjid,nagar kurnool, Mehboobnagar Andhra Pradesh 509209 08540-226731 9052707817 somisettygouthamraju@gmail.com

11) Orthopaedic Physically Handicapped No 12) Nationality 13) Subject Choice 14) Centre Choice 14.a) Choice -1 14.b) Choice -2 15) Educational Qualification 15.a) Qualifying Examination 15.b) Degree from 15.c) Name of State/Country 15.d) Name of College 15.e) Are you claiming relaxation in marks? 15.f) Relaxation Type Indian

16) Details of qualifying examination passed 16.a) Name of the Institute/University 16.b) Year of Admission 16.c) Year of Passing the examination 26.) Intership Details Status Completed Starting intership End intership 01 Jan 2011 31 Dec 2011 soochow university 19 Sep 2005 10 Jan 2010 27.) Medical Registration Details No. of days Registration Type Registration No. Registration Date Issuing Authority 365 Permanent 12-43876 17 May 2012 99 - MCI

UNDERTAKING/DECLARATION:
I hereby declare that the information furnished by me in the Application Form is correct and nothing has been concealed. In case any information furnished by me is found to be false, my candidature/registration/admission/service may be cancelled/terminated. I have not concealed any information. I realise that if any information furnished herein is found to be incorrect or untrue; I shall be liable to civil/criminal prosecution and also forgo my claim to the admission/appointment in the Institute.

28) Photo of Candidate

29) Signature of Candidate