APPLICATION FORM FOR ADMISSION IN Diagnostic Radiology Course ASSOCIATE OF APPLIED SCIENCE (AAS) SESSION 2013 at Dow Institute of Radiology Dow University of Health Sciences Karachi. Photograph Fill the form in block letters. Name of Applicant Father s Name Birth Date Birth Location Birth Country Age on closing date National ID. Or B Form. Marital Status Religion Male Female (Present) Tel. Mobile: (as mentioned in NIC) E-mail: Domicile Candidate s PRC Domicile Father s PRC Domicile Guardian s PRC Certificate. District Name Date of Issue Place of Issue (If any Professional education (Current or Past) ACADEMIC RECORD OF CANDIDATE Level of Study Name & Place of Institution Passing Year Matric / O Level Inter Science / A Level Interest in Profession other than MBBS & BDS ACADEMIC RECORD OF BROTHERS & SISTERS Level of Study Name & Place of Institution Passing Year Matric / O Level Inter Science / A Level
Particulars of Father/Mother/ Guardian Name Marital Status Relationship with Candidate Male Female National ID. Place of Issue (Present) (as mentioned in NIC) Tel. Mobile. E-mail: Fathes/Guardian Income Department Occupation Employer Designation Highest Eucation Level Citizenship of Province A) Did you do any Research Work? If yes give detail. Candidates Co-curricular Activities B) Are you good in any Sports? If yes give detail. NOTE: INCOMPLETE FORM WILL BE REJECTED Pay order of Rs.1500/- Entrance Test attached Matric Mark Sheet attached Matric Pass Certificate attached Candidate s Domicile attached Candidate s PRC attached Father s Domicile attached Father s CNIC attached Candidate s CNIC / B form attached Left hand thumb impression of Applicant Applicant s Signature Father s / Guardian Signature
CERTIFICATE FROM PRINCIPAL OF SCHOOL (LAST ATTENDED) This is to certify that Mr. / Miss Son / daughter of Mr. was a student of this school having been admitted into class from till Name of School Address of School Name of Student and Father s Name Permanent Address Date of Birth Distinctions (If any) Last Examination Passed (a) Seat. (b) Enrolment (c) Total Marks obtained / Maximum Marks (d) Division / Grade obtained Percentage Obtained It is further certified that during his/her, period of stay, conduct & character was Place Date SIGNATURE OF THE PRINCIPAL WITH SEAL
CERTIFICATE FROM PRINCIPAL OF COLLEGE (LAST ATTENDED) This is to certify that Mr. / Miss Son / daughter of Mr. was a student of this school having been admitted into class from till Name of School Address of School 1) Name of Students and Father s Name 2) Present address 3) Permanent Address 4) Last examination passed a. Date of Passing College Registration. b. Marks obtained in College examination (If held) before annual exam. Marks Obtained Max Marks (i) Physics (ii) Chemistry (iii)biology c. Total Marks Obtained / Maximum Marks e. Whether received any warning or punishment during the time when he/she was student of the college, if so give details It is further certified that during his/her period of stay in this college his/her work, conduct & character was Place Date SIGNATURE OF THE PRINCIPAL WITH SEAL
Health Certificate te: (Section A, B, & C will be filled by the candidate) Section A Name S/o, D/o Age Days Months Years Height: Weight: : Section B 1. Do you smoke?... 2. Do you take any medicine regularly?... If yes, Specify 3. Any history of allergy... 4. Do you suffer from any of the following diseases?... i. Epilepsy... ii. High Blood Pressure... iii. Psychiatric illness... iv. Rheumatic Heart Disease... v. Hepatitis B/C... vi. Physical Disability... If yes, Specify Section C Details of previous Vaccination Detail of Booster Vaccination 1. Measles... 2. Mumps... 3. Rubella... 4. Tetanus... 5. Pertussis... 6. Whooping Cough... 7. Hepatitis B... Certification: I hereby certify that the above information given by me is correct. Signature Father / Mother Signature
Fill all boxes with your present address Phone (Res.): Phone (Off.): Mobile. : Phone (Res.): Phone (Off.): Mobile. : Phone (Res.): Phone (Off.): Mobile. : Phone (Res.): Phone (Off.): Mobile. :
Dow University of Health Sciences, Karachi. ENTRY TEST ADMIT CARD FOR ADMISSIONS IN DIAGNOSTIC RADIOLOGY COURSE Dow Institute of Radiology Session 2013 Candidate s Copy Roll. Father s Postal Address: Please Paste (1 x 1) Photograph Tel : Mobile : E.mail: Signature of Candidate Date: For Official Use Left Hand Thumb Impression of Candidate Time: Venue: te: See Instructions Overleaf Signature Seal Father s Postal Address: Dow University of Health Sciences, Karachi. ENTRY TEST ADMIT CARD FOR ADMISSIONS IN DIAGNOSTIC RADIOLOGY COURSE Dow Institute of Radiology Session 2013 DUHS Copy Roll. Please Paste (1 x 1) Photograph Tel : Mobile : E.mail: Date: For Official Use Signature of Candidate Left Hand Thumb Impression of Candidate Time: Venue: Signature Seal