P. D. Hinduja Hospital

Application Form

P. D. Hinduja Hospital& Medical Research Center(Skill Development Center)

Affiliated By Maharashtra State Board of Skill Development (MSBSDE')

Form No. : 2022-23

Application Form for Full Time / Part TimeAllied Health Science program

(Form to be filled by Applicant in CAPITAL letter)
Course Type : Full time(FT) / Part Time(PT) (for working applicants with relevant exp.)

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Application form for provisional admission to the course in order of priority:

Name of the applicant

Date of Birth

Age

Religion

Caste category

Nationality

Aadhar Card No.

Pan Card/ Voter Id No.

Contact No.

Email Address

Address:

Address for communication

Pin code

Permanent communication

Pin code

Details of Parents/Guardian:

Father

Name:

Qualification:

Occupation:

Name & Address of workplace:

Phone No.

Email Id

Annual Income

MOTHER/GUARDIAN

Name:

Qualification:

Occupation:

Name & Address of workplace:

Phone No.

Email Id

Annual Income

Educational Qualification Details:

School Details

S.S.C.

Subjects studied

Month & year of passing

Board Name

Marks Obtained

Max Marks

Overall %

Higher Educational Details

H.S.C.

Subjects studied

Month & year of passing

College / University Name

Marks Obtained

Max Marks

Overall %

Degree Details

B.SC.

Subjects studied

Month & year of passing

College / University Name

Marks Obtained

Max Marks

Overall %

Other Certificates

B.SC.

Subjects studied

Month & year of passing

College / University Name

Marks Obtained

Max Marks

Overall %

Work Experience details:

Organisation name

Designation

From(dd/mm/yyyy)

To(dd/mm/yyyy)

Job Role

ADMISSION PROCEDURE : Candidates should submit the following documents with duly filled application form
3 passport size photographs	Experience Certificate if any		Aadhar card
X^th onwards all certificates and mark sheets (attested)	Cancelled cheque of your bank account		Pan Card/Voter Id
(For Office Use) Document Collected by		Verified by

FEES STRUCTURE: Fees can be paid in three instalments.Payment Details(DD/Cheque no.)
Total Fees^* (non- refundable)	`200 at the time of form submission `45000 + GST for six months courses `55000 + GST Tax for one year courses `78000 + GST Tax for two year courses
1st instalment : (at the time of admission + Post dated cheques for 2nd and 3rd installments)	On Admission `25000 + GST for six months courses `25000 + GST Tax for one year courses `40000 + GST Tax for two year courses
2nd instalment : (b/w1stSep. & 15thNov. after commencement of the course)	At the end of Ist month `20000 + GST Tax for six months courses `15000 + GST Tax for one year courses `20000 + GST Tax for two year courses
3rd instalment : (b/w1stSep. & 15thFeb. aftercommencement of the course)	At the end of 2nd month `15000 + GST Tax for one year courses `18000 + GST Tax for two year courses
Cheque / DD dishonoured by the bank will be charged at 500/ - per presentation, No candidate will be eligible to attend the course or the examination on non-payment of fees

*Fees & instalments paid will be non-refundable

DECLARATION:

I declare that the particulars given by me in this Application are correct. If any of the particulars given or documents submitted by me are not correct or false, my provisional admission will stand automatically cancelled without any intimation, notice or refund to me and I shall also be liable for any other punishment, penalty or legal action in such cases, I have clearly read and understood the fee structure and rules and regulations for the course given in the course brochure.

I fully understand that P. D. Hinduja Hospital & Medical Research Centre (HNH) is affiliated to Maharashtra State Board of Skill Development (MSBSDE) for listed courses. HNH has Life Supporter's Institute of Health Sciences (LIHS) as its administrative agency for running Allied Health Courses.
However, I also understand that P. D. Hinduja National Hospital & Medical Research Centre (HNH) and LIHS are not affiliated to any University, University Grants Commission, MCI, NCI or AICTE & this course is not recognized by any statutory agency. The course completion certificate shall be issued by HNH, LIHS & MSBSDE* on successful completion of all the requirements of the course and at sole discretion of HNH, LIHS & MSBSDE*.

*for affiliated courses only

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