Kings International Medical Academy

Student Registration Form

Complete Below Steps For Registration

Personal Details

Applying For :

First Name : *

Middle Name :

Last Name :

Phone Number : *

Phone number already exists

Telegram Number :

Whatsapp Number : *

Email : *

Email already exists

Gender :

Date of Birth :

Blood Group:

Nationality :

Photo :

Do you have a Passport? *
Yes No

Contact Details

Name of Father/Guardian: *

Phone Number: *

Email:

Father's Occupation:

Name of Mother/Guardian: *

Phone Number:

Email:

Mother's Occupation:

Communication Address: *

Country: *

State: *

District:

City: *

Pincode:

Same as Above

Permanent Address in home Country: *

Country: *

State: *

District:

City: *

Pincode:

Hostel Details

Do you require an hostel
Yes No

Center
Chennai Pune

Course Details

Responsible:

Name:

Occupation:

Relationship:

Contact Number:

Email:

Education Details

School Name:

Board:

School Address:

Country:

State:

District:

Year Of Passing:

10th Percentage:

Subject:

Marks:

School Name:

Board:

School Address:

Country:

State:

District:

Year Of Passing:

12th Percentage:

Subject:

Marks:

Name of BS/Pre Med Institution:

Year of BS/Pre Med:

Duration Of Course:

Name of Course:

Affiliated University:

Student Registration Form

Complete Below Steps For Registration

Personal Details

Contact Details

Family Details

Address

Hostel Details

Course Details

Responsible Person for Fee Payment

Education Details

10TH Details

10TH Marks Details

12TH Details

12TH Marks Details

B.S Details