M.K.C.G. Medical College, Berhampur, Odisha, India
Student Registration Form
Student Name *
Gender : *
Date of Birth : *
ID Proof Type : *
ID Proof No : *
Attachment of ID Proof Document : *Attach the PDF or JPG file of your Id Proof Document

Course : *
Year of Admission : *
NEET Roll No./ Registration.No : *

Blood Group : *
Father’s Name : *
Father’s Occupation : *
Mother's Name : *
Mother's Occupation : *
Reservation Category : *
Sub Category : *
Present Address : *
Address : *
State : *
Pin : *
Permanent Address (Same as present address )
Address : *
State : *
Pin : *
Contact Details of Student :
Mobile Number : *
Contact Details of Father/Mother :
Land Phone:
Mobile Number : *
Email id :
Last Qualifying Examination Details Of Student
Examination : * Year of Passing : * Name of College : * Board/University : * Remarks : *

I do hereby declare that the above details are true to the best of my knowledge and belief. In the event of any statement made above subsequently turning out to be incorrect or false, I am liable for necessary disciplinary action by the Institutional Authority.