Student Form

INSTITUTE OF PARAMEDICAL SCIENCE AND TECHNOLOGY

An Institute of Sirish Chandra Foundation
Vill-Brajalalchak, PO-Dakshinchak, NH-41, Near Haldia Gate
Haldia – 721654, Purba Medinipur, West Bengal, INDIA
E-mail: ipsthaldia@gmail.com, Website: www.ipsthaldia.in,

Student Form

First name

Last name

Birthday

Gender

Male Female

Father's Name

Father's Occupation

Mother's Name

Mother's Occupation

Nationality

Social Status

Highest Qualification

Course Applied For

Session Year

Permanent Address

House/Street No

Town/Village

Post Office

City

District

State

Mobile

Mailing Address Same as Pernament Address

House/Street No

Town/Village

Post Office

City

District

State

Mobile

Document to be submitted(Scanned Copy)

(document should be .jpg/.pdf/.png format, and max size 2 mb)

Passport Size Photo

Birth Certificate (If Available)

10th Standard Admit Card

10th Standard Mark Sheet

12th Standard Mark Sheet

Graduation Mark Sheet

Others (If Any)

Identity Proof(Any One)

Identity Type

Attached Document

Scanned Signature

Payment Details

Mode of Payment

DD/Cheque No./ Transaction Id

Date

Amount Transferred(Rs.)