Application Form

सी. एम. एस. ई. डी. ग्रामीण स्वास्थ्य शिक्षण संस्थान लखनऊ (उ० प्र०) > Application Form

Student Admission Form

Application Date

Select Branch

Course Name

Session

Batch

Name

Father's Name

Mother's Name

Date of Birth

Gender

Male

Female

Transgender

Category

Permanent Address/Village/Mohalla

Post

Block

Sub Division

District

State

Email*

Mobile No.

Whats App No.

Corresponding Address/Village/Mohalla

Post

Block

Sub Division

District

State*

Any One ID Details (Aadhar Card, Voter Card, Driving Licence, Ration Card, Bank Passbook, PAN Card, Passport) Number

Educational Qualification

Sl No.	Examination	Board/University	Year of Passing	Marks Obtained	Total Marks	Percent of Marks
1	High School
2	Intermediate

Additional Qualification

Upload passport size photo

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Upload High School Certificate

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Upload Highschool Marksheet

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Upload Adhaar Card(Front)

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Upload Adhaar Card(Back)

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Upload Signature

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Declaration

I declare that all the information and statement given by me as above are true and correct. If any information and statement are found to be wrong and false submitted by me at any stage, any disciplinary action can be taken by authority.

Sig. & Stamp Area Supervisor

Signature of Candidate

Code

Report Date

Full Name