APPLICATION FORM FOR UNDERGRADUATE PROGRAMS IN MEDICINEFOR ADMISSION 2022 - 2023 Registration Instructions:Step 1: Fill Application and Update all the required information. Step 2: On the Next Page Make Payment. Registration Form PERSONAL INFORMATIONHiddenPh.D. Application NumberApplicant's Name: (In Block Letters)* Passport size photo*Accepted file types: jpg, jpeg, png, gif.Date of Birth* DD slash MM slash YYYY Age*Gender* Male Female Transgender Nationality* Indian Foreign FOR NRI / INTERNATIONAL APPLICANTS City and Country of Birth Passport Number Type of Visa Date of Expiry of Visa Marital status* Single Married Religion* Hindu Christian Muslim others If Other Religion, Specify* Caste* Community* OC BC MBC OBC SC ST Attested Photocopy of the Community CertificateMax. file size: 2 MB.Aadhaar Number* Please provide AADHAAR Proof*Accepted file types: pdf, Max. file size: 2 MB.Phone No. / Mobile No.*Email* Physically Challenged* Yes No if Yes, Mention the Type of Disability* Please provide Certificate of Disability attested by competent authority)*Accepted file types: pdf, Max. file size: 2 MB.Permanent Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Address for Correspondence* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Are you the first graduate of your family?* Yes No Do you have any siblings studying in MAHER ?* Yes No If yes, Mention the Sibling Details* Name of the Student Year of Study : Name of the Institution PARENT /GUARDIAN INFORMATIONFather’s / Legal Guardian’s Name:* Father’s / Legal Guardian’s Occupation:* Father’s / Legal Guardian’s Designation: Father’s Residential Contact Number:* Father’s Office Contact No.: Father’s Email ID:* Attested Photocopy of the Father’s Aadhaar card*Max. file size: 2 MB.Father’s / Legal Guardian’s Office Address:*Mother’s Name:* Mother’s Occupation:* Mother’s Designation:* Mother’s Res Contact No.:* Mother’s Office Contact No.: Mother’s Email ID: Attested Photocopy of the Mother’s Aadhaar card*Max. file size: 2 MB.Mother’s Office Address:Please indicate your family’s gross income for the financial year 2021 - 2022 :*Attested Photocopy of the Income Certificate of the parentMax. file size: 2 MB.Whether either of your Parents were in the Defence Service?* Yes No If yes, Provide Details : (Please attach Proof )*Accepted file types: pdf, Max. file size: 2 MB.ACADEMIC DETAILS OF THE APPLICANTHSC (+2) DetailsName of the School Educational Board Medium of Instruction Month & Year of Passing Total Marks ObtainedPercentageAttested Photocopy of 12th Mark SheetsMax. file size: 2 MB.SSLC (10th) DetailsName of the School* Educational Board* Medium of Instruction* Month and Year of Passing* Total Marks Obtained*Percentage*Attested Photocopy of 10th Mark Sheets*Max. file size: 2 MB.Details of Marks secured in Qualifying Examinations (HSC Examination Marks)Subject 1 Marks securedMaximum MarksSubject 2 Marks securedMaximum MarksSubject 3 Marks securedMaximum MarksSubject 4 Marks securedMaximum MarksSubject 5 Marks securedMaximum MarksSubject 6 Maximum MarksMarks securedNEET DetailsNEET Details NEET Registration Number NEET Score NEET Rank NEET Details NEET Roll No. NEET Category Attested Photocopy of the Transfer CertificateMax. file size: 2 MB.Attested Photocopy of Conduct CertificateMax. file size: 2 MB.Attested Photocopy of Migration Certificate (For all except Tamil Nadu State Board Students) - (If applicable)Max. file size: 2 MB.Attested Photocopy of Nativity / Domicile Certificate (If applicable)Max. file size: 2 MB.CHOICE OF PROGRAM1st Choice:*MBBS - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.D. Biochemistry - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.D. Pharmacology - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.D. Pathology - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.D. Microbiology - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.D. Community Medicine - Meenakshi Medical College Hospital and Research Institute, KanchipuramM. D. General Medicine - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.D. Respiratory Medicine - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.D. Dermatology - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.D. Psychiatry - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.D. Pediatrics - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.S. Orthopedics - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.S. General Surgery - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.S. Ophthalmology - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.S. E.N.T. - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.D. Radiodiagnosis - Meenakshi Medical College Hospital and Research Institute, KanchipuramM. D. Anesthesiology - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.S. Obstetrics &Gynecology - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.D. Anatomy - Meenakshi Medical College Hospital and Research Institute, KanchipuramM. D. Physiology - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.Ch. Urology - Meenakshi Medical College Hospital and Research Institute, KanchipuramD.M. Cardiology - Meenakshi Medical College Hospital and Research Institute, KanchipuramD.M.Gastroenterology - Meenakshi Medical College Hospital and Research Institute, KanchipuramD.M. Neurology - Meenakshi Medical College Hospital and Research Institute, KanchipuramMSc. Biochemistry - Meenakshi Medical College Hospital and Research Institute, KanchipuramMSc. Anatomy - Meenakshi Medical College Hospital and Research Institute, KanchipuramMSc. Microbiology - Meenakshi Medical College Hospital and Research Institute, KanchipuramMSc. Pharmacology - Meenakshi Medical College Hospital and Research Institute, KanchipuramMSc. Physiology - Meenakshi Medical College Hospital and Research Institute, Kanchipuram2nd Choice:*MBBS - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.D. Biochemistry - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.D. Pharmacology - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.D. Pathology - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.D. Microbiology - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.D. Community Medicine - Meenakshi Medical College Hospital and Research Institute, KanchipuramM. D. General Medicine - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.D. Respiratory Medicine - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.D. Dermatology - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.D. Psychiatry - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.D. Pediatrics - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.S. Orthopedics - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.S. General Surgery - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.S. Ophthalmology - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.S. E.N.T. - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.D. Radiodiagnosis - Meenakshi Medical College Hospital and Research Institute, KanchipuramM. D. Anesthesiology - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.S. Obstetrics &Gynecology - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.D. Anatomy - Meenakshi Medical College Hospital and Research Institute, KanchipuramM. D. Physiology - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.Ch. Urology - Meenakshi Medical College Hospital and Research Institute, KanchipuramD.M. Cardiology - Meenakshi Medical College Hospital and Research Institute, KanchipuramD.M.Gastroenterology - Meenakshi Medical College Hospital and Research Institute, KanchipuramD.M. Neurology - Meenakshi Medical College Hospital and Research Institute, KanchipuramMSc. Biochemistry - Meenakshi Medical College Hospital and Research Institute, KanchipuramMSc. Anatomy - Meenakshi Medical College Hospital and Research Institute, KanchipuramMSc. Microbiology - Meenakshi Medical College Hospital and Research Institute, KanchipuramMSc. Pharmacology - Meenakshi Medical College Hospital and Research Institute, KanchipuramMSc. Physiology - Meenakshi Medical College Hospital and Research Institute, Kanchipuram3rd Choice:*MBBS - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.D. Biochemistry - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.D. Pharmacology - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.D. Pathology - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.D. Microbiology - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.D. Community Medicine - Meenakshi Medical College Hospital and Research Institute, KanchipuramM. D. General Medicine - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.D. Respiratory Medicine - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.D. Dermatology - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.D. Psychiatry - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.D. Pediatrics - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.S. Orthopedics - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.S. General Surgery - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.S. Ophthalmology - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.S. E.N.T. - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.D. Radiodiagnosis - Meenakshi Medical College Hospital and Research Institute, KanchipuramM. D. Anesthesiology - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.S. Obstetrics &Gynecology - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.D. Anatomy - Meenakshi Medical College Hospital and Research Institute, KanchipuramM. D. Physiology - Meenakshi Medical College Hospital and Research Institute, KanchipuramM.Ch. Urology - Meenakshi Medical College Hospital and Research Institute, KanchipuramD.M. Cardiology - Meenakshi Medical College Hospital and Research Institute, KanchipuramD.M.Gastroenterology - Meenakshi Medical College Hospital and Research Institute, KanchipuramD.M. Neurology - Meenakshi Medical College Hospital and Research Institute, KanchipuramMSc. Biochemistry - Meenakshi Medical College Hospital and Research Institute, KanchipuramMSc. Anatomy - Meenakshi Medical College Hospital and Research Institute, KanchipuramMSc. Microbiology - Meenakshi Medical College Hospital and Research Institute, KanchipuramMSc. Pharmacology - Meenakshi Medical College Hospital and Research Institute, KanchipuramMSc. Physiology - Meenakshi Medical College Hospital and Research Institute, KanchipuramJoint Declaration* I hereby affirm that the particulars given in the application are true and correct. I / We also agree to abide by the Rules and Regulations of Meenakshi Academy of Higher Education and Research