yen ARMY COLLEGE OF DENTAL SCIENCES ACDS Nagar(Chennapur-CRPF Road) Jai Jawaharnagar Post, Secunderabad, APPLICATION FORM FOR ADMISSION TO BACHELOR OF DENTAL SURGERY Ci ( Please read Prospectus and Instructions given at reverse of this Form carefully before filling ‘up the F = 500 087 “OURSE - 2011 (Please read Inst tions and codes given in side -2 before filling up the Form) Application Number (To be filled by ACDS only) I, Name of the Candidate (Write in Capital letters only) ofthe Father? ‘Mother as applicable with Rat ‘3 Unit address of Parent (Presently serving /From where retired) 4 Date of Birth STs your parentan Award Winner Ife pve hort wane and Code (6. Exam Centre: 7. Nationality (ay Cone Coe coe 7 Dato perormancs in ualiing eam (B) Year of appearing / - (E) % of marks (A) Qualifying Exam passing qualifying exam (C)Maximum Marks (D) Marks Secured Physics Chemistry Biology 9c ave you paused the qualifying exam with | 10/Sex 1 Tegour Fhe /Motberrervng Im Tndlan Ary or Piy-chem Bio taken together st oe and the reed from Ind Army ane drawing Pens ay As Mo ao TE yor part has sought eles Tom Ara, | 15 la yourFatherfother on? Tout aolonng Indicate whether drawing or | (A) AL~ Deputation (B)Al-Assam Rifles 3. N D4 - Not Applicable D4. GREF 3 is ES - Any other(Specify) Ti: Wns your Faker tier common in Army ay Yes a Medical Corpathrey Dena CorpuMINS bet \S.leyourFathevMather A Ys Medial Corp Army Dental Corp seving infeed fom ApS? BEN 16. Your Cell Number / Residence A7E-mall: 18, Postal Address (Use Black/Blue ballpoint pen in BLOCK) 19, Signature of the Candidate (Use Bluck/Be bal point pe oy) Name: —___] Address: 20, Photograph UNDERTAKING PINCODE declare that the above information furnished is true to the best of my ‘nowledge Ifthe information is proved to be fale on verification subsequently, Tam liable to forgo the employment fered to me Paste your recent color Photog. ‘ete with ize 3.Sem X 4 Sem DO NOT PIN OR STAPPLE THE PHOTOGRAPHINSTRUCTIONS FOR FILLING UP THE FORM 1. Use BLOCK LETTERS only to fill the form. Leave one box between the words. Example: |R|E|N|U P/A|R|M|A/R 2. Application shall be made in original form only and not in photo copied form. Application forms downloaded through website will be entertained only when forwarded along with DD of Rs 700 /- in favour of ACDS, Secunderabad. 3. Write your name as given in the SSC or X class certificates. 4. Enter date of birthas |2/2]-|0/7]-|1/9/8/1 5. Write Al, B2,, C3...ete in the boxes as applicable as shown against each box. All B\2 c|3 6. Applicant whose parents are Award Winner will enter Short Name & Code No. as shown below Award Short Name Code No. (a) Param Vir Chakra Pvc ES (b) Ashok Chakra AC ES (©) Maha Vir Chakra MYC D4 (q) Kirti Chakra KC D4 (©) Vir Chakra vre C3 (© Shaurya Chakra sc c3 (g) Sena Medal SM AL (b) Sarvottam Yudh Seva Medal SYSM C3 (@ Uttam Yudh Seva Medal UYsM B2 @_Yudh Seva Medal YSM Al (k) Mention in Dispatches M-in-D AL (War Widows ww ES Note: Write the relevent code in the boxes i.e., A1,B2 ete, wherever applicable in following manner: A/1//B/2||C/3/|D)/4|/E/5 7. Write your address for correspondence and affix postal stamps (Rs.30/-) on envelope for sending Admit Card and enclose it in the main envelope alongwith application form. 8. Write your address on acknowledgement card and affix postal stamp of Rs.5/- and enclose it in main envelope alongwith application form. 9. Please do not Staple, Pin or Tag certificates to the Application Form.