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B.L.D.E.

University
(Declared vide notification No. F.9-37/2007-U.3 (A) Dated. 29-2-2008 of the MHRD,
Government of India under Section 3 of the UGC Act, 1956)
Comprising Shri. B. M. Patil Medical College, Hospital and Research Centre,
Smt. Bangaramma Sajjan Campus, Sholapur Road, Bijapur – 586103, Karnataka, India.
Phone: +91-08352 – 262770, Fax: +91 – 08352 - 263303,
Website: www.bldeuniversity.org email: office@bldeuniversity.org

Recent
Application form for admission to Photograph
M.Sc programme in the Faculty of Medicine taken
within 6
months

1 Name in full (in capital letters)

Permanent address in full


2
(Telephone number and E-mail id if any)

Address for correspondence


3
(Telephone number and E-mail id if any)

4 Sex

5 Nationality

6 Date of birth

7 Details about graduate degree


(3 years / B.Sc)
S.No. Degree Name of the Year of Subject Division /
College/University passing studied grade

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Are you an employee of this
8
Institute ? If so furnish the details

Whether all documents listed in


9
annexure is enclosed or not

I hereby declare that all statements made in this application are true, complete and correct to the best of
my knowledge and belief. I understand that in the event of any information being found false or
incorrect my candidature for M.Sc. programme is liable to be cancelled by the University.

Date: Signature of the candidate

Place:

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