THE WEST BENGAL UNIVERSITY OF HEALTH SCIENCES DD - 36, Sector - 1, Salt Lake, Kolkata - 700 064 Telephone.: (033) 2321- 3461 / 2334- 6602

Online Application for Entrance Examination 2011 for MD (Homoeopathy)

PERSONAL DETAILS

1.Candidate Name* 2.Father's Name* 3.Gender* Male Female 4.Caste* Select Caste General Scheduled Caste Scheduled Tribe Other Backward Class 5.Religion* Select Religion Hindu Muslim Buddhist Jain Christian Sikh Others 6.Date of Birth* mm/dd/yyyy 7.Physically Challenged Yes No

CONTACT & COMMUNICATION DETAILS

8.Communication Address where admit card is to be mailed line1&2* [Don't write district, state, pin here, fill them in adjacent fields] 9.District / Town / City* 10. State* Select State Andaman Andhra Pradesh Arunachal Pradesh Assam Bihar Chhattisgarh Daman Delhi Diu Goa Gujarat Haryana Himachal Pradesh Jammu Jharkand Karnataka Kashmir Kerala Lakshadeep Madhya Pradesh Maharashtra Manipur Meghalaya Mizoram Nagaland Orissa Ouside India Pondicherry Punjab Rajasthan Sikkim Tamil Nadu Tripura Uttar Pradesh Uttaranchal West Bengal 11.Pin* 12.Telephone 13. Mobile* 14.Email 15.Nationality* Select Nationality Indian Others

REGISTRATION DETAILS

16.University from which passed BHMS max 100 char 17.Date/likely date of completion of one year Internship (pick from calendar)* mm/dd/yyyy 18.Is the candidate pursuing any other course?* Select Yes No 19.If yes, date of completion of such course (pick from calendar) mm/dd/yyyy 20.Medical Registration Type Select Registration Type Permanent Provisional 21.Medical Registration No max 10 char 22.Date of Registration (pick from calendar) mm/dd/yyyy 23.Name of the Council of Registration max 100 char

DRAFT DETAILS

MD (Homoeopathy) (Rs 1000) 24.Bank name 25.Draft Number