Application No………….../2017
BCF COLLEGE OF PHYSIOTHERAPY
INDO-AMERICAN HOSPITAL
(A unit of Bahuleyan Charitable Foundation)
Chemmanakary, Vaikom, Kottayam - 686143
Website: www.bcfcollegeofphysiotherapy.com
Application for Admission under the Management/Government/NRI Quota to the
B.P.T. Course for the year 2017-2018
1
Name of the Applicant (in block letters)
2
Age and Date of Birth
3
Sex
4
Marital Status
Married / Unmarried
5
Religion& Caste, and Nationality
6
Encircle the category you belong to
SC/ ST/ OBC/ OEC/GENERAL
7
Educational Qualification
8
Number of Appearance in Qualifying Exam.
Marks secured in
Qualifying Exam.
Physics
Chemistry
Biology
Science
Subject
Total
English
Grand
Total
Grade
Total Marks
Marks Secured
%
9
Particulars of other qualifications, if any; sports/games
and other extra curricular activities
10
Address of the College/HSS where the applicant last
studied [Enclose copy of T.C.]
11
Name of Father, and Occupation
12
Name of mother, and Occupation
13
Permanent Address & Tel. No. with STD code/Mobile
Phone No.
14
Present Address & Tel. No. with STD code/ Mobile
Phone No.
15
Name and Address of Guardian
16
Relationship of applicant with Guardian
PHOTO
( Front View)
17
Whether the applicant requires hostel accommodation
Yes / No
18
Whether applying for open management Quota/NRI
quota Seat
Declaration by the Applicant
I, ……………………… hereby declare that I have carefully gone through the Prospectus and I
promise to abide by the rules and regulations. I further declare that I have no Physical or Mental
disabilities that disqualify me for admission. The statements made by me in this application and the
documents produced in support thereof are true to the best of my knowledge. I also declare that I will
not involve in any activity related to indisciplinary action and ragging and if found involved, I am
ready to accept any punishment imposed, on me by the authorities.
I Mr./Ms………………………………… Roll No………………..program BPT student of BCF
College of Physiotherapy do hereby undertake .
1. That I have read and understood the directives of the Hon’ble Supreme Court of India on anti
–ragging and the measures proposed to be taken in the above references. (Available at
https://antiragging.in/).
2. That I understood the meaning of Ragging and know that the ragging in any form is a
punishable offence and the same is banned by the Court of law.
3. That I have not been found or charged for my involvement in any kind of ragging in the past.
However, I undertake to face disciplinary action/legal proceedings including expulsion from
the institute if the above statement is found to be untrue or the facts are concealed, at any stage
in future.
4. That I shall not resort to ragging an any form at any place and shall abide by the rules/laws
prescribed by the Courts, Govt.of India and the Institute authorities for the purpose from time
to time.
Name & Signature of the Student……………………
I hereby fully endorse the undertaking made by my child/ward
Signature of Mother / Father and or Guardian
Name and Address
Place:……………
Date:…………..
Witness:………………..
Note: The duly filled in application and supporting documents should along with self-addressed intimation
card reach this office on or before 15.06.2017, 4 PM
……………………………………………………………………………………
FOR OFFICE USE ONLY
Verified and found correct Rank………………………...
Admission details Marks obtained……………...
Admission number………. …………dt…………………………Category……………………………..
College Fee paid……………………. Hostel Fee paid……………..
Rt. No………….dt…………………. Rt.No………….dt…………
