B. Pharm. (Lateral Entry to Second year)

Note : Kindly submit "NA" in the fields wherever left blank.

Personal Information Data

Personal Information Data:

*Name :

Names as per 12th (10+2) or equivalent marksheet, same will appear in the marksheet and certificate. If you do not have Last Name you may enter (.) dot.

*Father's Name :

*Mother's Name :

*Upload Photo :

*Date of Birth:

*Blood Group:

*Gender :

Male Female

*Category:

*University/Board:

Minority (If Any) :

* Differently abled?:

*Age :

*Nationality :

*Marital Status:

*Domicile :

*Mother Tongue :

Region :

*Disability (if Yes) :

*APPLICANT'S ADDRESS :

*Mobile :

*E-Mail :

*Preference :

ACADEMIC PERFORMANCE (Stages of Education) :

Class 10th Details:

*Name of the School :

*Marks / Grade Obtained :

*Month & Year of Completion :

*X/SSC Board :

*Max Marks / Grade:

*Enrollment No.:

*X/SSC %age:

Class 12th Details :

*Name of the School/College:

*XII/HSC Board:

*Marks / Grade Obtained :

*Max Marks / Grade:

*XII/HSC %age:

*Month & Year of Completion :

*Enrollment No.:

*Stream :

Diploma Details :

*Name of the Institute :

*University Name:

*Marks Obtained :

*Max Marks / Grade (conversion into Marks if grade provided) :

*Diploma percentage- Aggregate should be minimum 60% (inclusive of all years):

*Month & Year of Completion :

FAMILY BACKGROUND :

*Father's / Guardian's Name :

*Occupation :

* Father's Office Address :

*Mother's Name :

*Mother's Occupation :

*Mother's Office Address :

*ANNUAL FAMILY INCOME :

*PERMANENT ADDRESS :

*LOCAL GUARDIAN'S NAME :

*LOCAL GUARDIAN'S ADDRESS :

Declaration by the Candidate and Parents :

I certify and declare that the information provided by me in the Pre-Admission Online Registration Form for B. Pharm – lateral entry 2017 is true and correct. In case of any discrepancy and / or submission of incomplete form, I am aware that my form will be rejected. In that case I shall lose my claim on the admission and will not hold NMIMS University authorities responsible for the same. Further, the registration fees paid my me will be forfeited.