SRI JAYENDRA SARASWATHI AYURVEDA COLLEGE & HOSPITAL
Chennai – Bangalore Highway, Nazarathpet, Chennai – 600 123
Ph: +91-44-2649 2649 / 2627 4583 | Web: www.sjsach.org.in | Email: sjsach@gmail.com
DEPT OF SRI CHANDRASEKHARENDRA SARASWATHI VISWA MAHAVIDYALAYA
(University u/s 3 of the UGC Act. 1956)
Enathur, Kancheepuram – 631 561
dd
mm
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Appl. No.
Application for Admission to BAMS Degree Course
INSTRUCTIONS
1. Please use CAPITAL LETTERS & Blue or Black Ball Point for filling up the form.
2. Only Forms complete in all aspects will be processed.
Please paste a recent
passport size photograph
For Office Use
here with Name & DOB
entered on the back
FULL NAME
DOB
FATHER’S NAME
MOTHER’S NAME
RELIGION
NATIONALITY
CONTACT DETAILS
SEX
dd
mm
yyyy
AGE
MOTHER TONGUE
AGE
AGE
COMMUNITY
MARITAL STATUS
COMMUNICATION ADDRESS
B.GROUP
□ OC
PROFESSION
PROFESSION
□ BC
□ MBC
□ SC
□ ST
□ Others
PERMANENT ADDRESS
NAME
HOUSE NAME / NO
STREET NAME 1
STREET NAME 2
AREA / LOCALITY
VILLAGE / CITY
DISTRICT
STATE
PINCODE
LANDLINE
MOBILE
EMAIL ID
A.
Academic Qualification (From School to Current – Kindly Attach attested copies of all Certificates)
Qualification
Institute name &
Address
University / Board
Yr of Passing
English
Tamil
Malayalam
Attempts
Marks in %
SSC / Equivalent
(Specify)
HSC / Equivalent
(Specify)
Others (Specify)
Languages Known
Speak
Read
Write
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Sanskrit
Hindi
Telugu
Kannada
Downloded from www.sjsach.org.in
SRI JAYENDRA SARASWATHI AYURVEDA COLLEGE & HOSPITAL
Chennai – Bangalore Highway, Nazarathpet, Chennai – 600 123
Ph: +91-44-2649 2649 / 2627 4583 | Web: www.sjsach.org.in | Email: sjsach@gmail.com
DEPT OF SRI CHANDRASEKHARENDRA SARASWATHI VISWA MAHAVIDYALAYA
(University u/s 3 of the UGC Act. 1956)
Enathur, Kancheepuram – 631 561
Details of Marks obtained in Qualifying Exams
HSC / Intermediate / Pre Degree / Other Equivalent (Specify)
Subject
Marks Obtained
Minimum Pass Mark
Maximum Marks
Attempts
Biology
Botany
Zoology
Physics
Chemistry
Mathematics
English
Mother Tongue
(Specify)
Others (Specify)
Hobbies
Computer Knowledge
Name of two References whom we could get in touch if required
Name
Designation
Address
City
State
Phone
Mobile
Email ID
Voluntary Disclosure
1.
2.
3.
4.
5.
6.
7.
8.
Do you have any relatives studying in this college?
Do you suffer from any medical problem?
Have you ever participated in any activity related to social work
Have you ever participated or contemplated to participate in activities related to trade union / politics
Have you ever participated in activities related to terrorism / any anti-social activity?
Has any case or FIR or complaint been registered against you or is pending registration for any offence?
Are you physically challenged?
Do you have a habit of drinking alcohol or smoking?
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Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Downloded from www.sjsach.org.in
SRI JAYENDRA SARASWATHI AYURVEDA COLLEGE & HOSPITAL
Chennai – Bangalore Highway, Nazarathpet, Chennai – 600 123
Ph: +91-44-2649 2649 / 2627 4583 | Web: www.sjsach.org.in | Email: sjsach@gmail.com
DEPT OF SRI CHANDRASEKHARENDRA SARASWATHI VISWA MAHAVIDYALAYA
(University u/s 3 of the UGC Act. 1956)
Enathur, Kancheepuram – 631 561
Declaration by the Applicant
• I hereby solemnly affirm that the information furnished in my application form and also enclosures thereto
submitted by me are true. Should it however be found that any information furnished therein is untrue in material
Particulars, I realize that I am liable to criminal prosecution and also agree to forego my seat in the college.
• I hereby agree, to abide by the rules and regulations at present in force or that may be hereafter framed for the
governance of the college and its attached Hospital, Hostels and I undertake that so long as I am a student of the
College. I do nothing either inside or outside the College and Hospital that will interfere with the orderly
Governance and discipline.
• I hereby agree to make good if any loss or damage to books, apparatus, furniture and other belongings to college
and its attached Hospital and Hostels, which may be caused by my carelessness, negligence or wantonness on my
part.
• I hereby assure that I will not indulge myself in any form of anti-social and prohibitive activities such as
RAGGING or any kind of harassment-physical or otherwise. I am fully aware of the provisions of Indian Penal
Code relating offences connected with hurt, endangerment of life or personal safety, wrongful confinement,
assault, criminal intimidation and so on and if I am found indulging myself in such prohibitive and anti-social
Activities. I am liable for severe punishment including removal from the college and handing over to the police.
• I hereby declare that I hold myself responsible for the timely payment of fees to the college during the period of
my studies, till I complete the course. I am aware that I have to pay entire course fee, even if I discontinue the
Course.
• It is brought to my notice that fees once paid will not be refunded at any cost.
• I hereby declare that I abide by the above mentioned rules. I also declare that I have carefully gone through the
Instructions to candidates herein mentioned and agree for the same.
Date:
Place:
Declaration by Parent / Guardian
Signature of the Applicant
I, Ms./Mr./Mrs. ……………………………………………………………………………………………………………………………. do hereby guarantee
that my son / daughter / ward ……………………………………………………………………………………………….. if given admission for this
course at Sri Jayendra Saraswathi Ayurveda College and Hospital will not take part in any activity prejudicial to the
interest of the Institution. I vouch for his / her good behavior and conduct during the course of studies.
He / She is liable for appropriate disciplinary action, taken by the college in case of violation of the prescribed rules and
regulations. I am agreeable to execute a bond if any, if my son / daughter takes admission in the said course.
Date:
Place:
For Office Use
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Signature of the Parent/Guardian
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SRI JAYENDRA SARASWATHI AYURVEDA COLLEGE & HOSPITAL
Chennai – Bangalore Highway, Nazarathpet, Chennai – 600 123
Ph: +91-44-2649 2649 / 2627 4583 | Web: www.sjsach.org.in | Email: sjsach@gmail.com
DEPT OF SRI CHANDRASEKHARENDRA SARASWATHI VISWA MAHAVIDYALAYA
(University u/s 3 of the UGC Act. 1956)
Enathur, Kancheepuram – 631 561
INSTRUCTIONS TO THE STUDENT
1. Application to be filled by Blue or Black Ballpoint pen only.
2. Incomplete Application will not be valid.
3. Certificates to be enclosed:i.
S.S.C./ Equivalent Certificates
ii.
H.S.C./Equivalent Certificates
iii.
Others, if any
iv.
Passport size photos 2
v.
Community Certificate
vi.
Transfer Certificate
vii.
Conduct Certificate
viii.
Physical Fitness Certificate
ix.
Physically challenged Certificate
x.
Extra Curricular activities
To be sent to the address given below.
The Principal,
Sri Jayendra Saraswathi Ayurveda College & Hospital,
Nazarathpet,
Chennai – 600 123.
Phone No.044-26492649 & 26274583
4. Please super scribe the envelope as “BAMS Application”
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