Welcome To MKCG Medical College

Student Registration Form

Student Name *

Gender : *

Date of Birth : *

ID Proof Type : *

ID Proof No : *

Attachment of ID Proof Document : *

Course : *

Year of Admission : *

NEET Roll No./ Registration.No : *

Blood Group : *

Father’s Name : *

Father’s Occupation : *

Attach Passport Photo Of Student : *

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 : *

Email id : *

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 : *

Captcha : *

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Attach Signature Of Student : *

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.

Maharaja Krushna Chandra Gajapati Medical College & Hospital, Berhampur