<div class="contentInside onlineform">[return_message]
<form name="application-form" id="application-form" method="post">
<input type="hidden" name="command-form" value="APP_FORM"/>
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<div class="firstline">SHREE DEVI COLLEGE OF PHYSIOTHERAPY</div>
<div class="secondline">(Affiliated to Rajiv Gandhi University of Health Sciences, Bangalore & Approved by IAP)</div>
<div class="thirdline">Application for Admission to B. P.T. / M.P.T. Course</div>
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<div class="application_form">
<table cellspacing="0" cellpadding="6" border="0" width="550">
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<td valign="top">1. Name of the candidate in full (block letters) to be entered as found in the certificate of the qualifying examination.<span class="required"> *</span></td>
<td valign="top">
                     <span class="wpcf7-form-control-wrap your-name"><input type="text" name="your-name" value="" class="wpcf7-text wpcf7-validates-as-digit application_form_input" size="40"></span>
                  </td>
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<tr>
<td valign="top">2. Father’s Name</td>
<td valign="top">
                    <span class="wpcf7-form-control-wrap father-name"><input type="text" name="father-name" value="" class="wpcf7-text application_form_input" size="40"></span>
                    </td>
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<td valign="top">3. Mother’s Name</td>
<td valign="top">
                    <span class="wpcf7-form-control-wrap mother-name"><input type="text" name="mother-name" value="" class="wpcf7-text application_form_input" size="40"></span>
                    </td>
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<tr>
<td valign="top">4. Name of the guardian and relationship (if father is not alive)</td>
<td valign="top">
                    <span class="wpcf7-form-control-wrap guardian-name"><input type="text" name="guardian-name" value="" class="wpcf7-text application_form_input" size="40"></span>
                  </td>
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<td valign="top">5. Permanent address of father or guardian</td>
<td valign="top">
                    <span class="wpcf7-form-control-wrap permanent-address"><textarea name="permanent-address" class="wpcf7-validates-as-required application_form_input" cols="31" rows="4"></textarea></span>
                  </td>
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<td valign="top">6. a) Telephone Numbers – Parents Mobile No<span class="required"> *</span></td>
<td valign="top">
                    <span class="wpcf7-form-control-wrap parent-mobile-number"><input type="text" name="parent-mobile-number" value="" class="wpcf7-text application_form_input" size="40"></span>
                  </td>
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<td valign="top">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Students  Mobile No</td>
<td valign="top">
                    <span class="wpcf7-form-control-wrap student-mobile-number"><input type="text" name="student-mobile-number" value="" class="wpcf7-text application_form_input" size="40"></span>
                  </td>
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<td valign="top">&nbsp;&nbsp;&nbsp;&nbsp;b) Email Address – Parents<span class="required"> *</span></td>
<td valign="top">
                    <span class="wpcf7-form-control-wrap parent-email-address"><input type="text" name="parent-email-address" value="" class="wpcf7-text application_form_input" size="40"></span>
                  </td>
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<td valign="top">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Students</td>
<td valign="top">
                    <span class="wpcf7-form-control-wrap student-email-address"><input type="text" name="student-email-address" value="" class="wpcf7-text application_form_input" size="40"></span>
                  </td>
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<tr>
<td valign="top">7. Religion and Caste</td>
<td valign="top">
                    <span class="wpcf7-form-control-wrap religion-caste"><input type="text" name="religion-caste" value="" class="wpcf7-text application_form_input" size="40"></span>
                    </td>
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<tr>
<td valign="top">8. Whether you belong to Scheduled Caste / Scheduled Tribe / Backward Class. State sect if you belong to Any one of these categories.</td>
<td valign="top">
                    <span class="wpcf7-form-control-wrap category"><input type="text" name="category" value="" class="wpcf7-text application_form_input" size="40"></span>
                    </td>
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<td valign="top">9. Occupation of Father / Guardian</td>
<td valign="top">
                  <span class="wpcf7-form-control-wrap parent-occupation"><input type="text" name="parent-occupation" value="" class="wpcf7-text application_form_input" size="40"></span>
                  </td>
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<tr>
<td valign="top">10. Annual Income of Father / Guardian </td>
<td valign="top">
                   <span class="wpcf7-form-control-wrap parent-annual-income"><input type="text" name="parent-annual-income" value="" class="wpcf7-text application_form_input" size="40"></span>
                  </td>
</tr>
<tr>
<td valign="top">11. a] Date of Birth (In Christian era)</td>
<td valign="top">
                    <span class="wpcf7-form-control-wrap dateofbirth"><input type="text" name="dateofbirth" value="" class="wpcf7-text application_form_input" size="40"></span>
                  </td>
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<tr>
<td valign="top">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;b] Place of Birth (Here enter Place, Taluk &amp; District)</td>
<td valign="top">
                    <span class="wpcf7-form-control-wrap placeofbirth"><input type="text" name="placeofbirth" value="" class="wpcf7-text application_form_input" size="40"></span>
                  </td>
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<tr>
<td valign="top">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;c] State of domicile</td>
<td valign="top">
                    <span class="wpcf7-form-control-wrap stateofdomicile"><input type="text" name="stateofdomicile" value="" class="wpcf7-text application_form_input" size="40"></span>
                  </td>
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<td valign="top">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;d] Mother tongue</td>
<td valign="top">
                    <span class="wpcf7-form-control-wrap mothertongue"><input type="text" name="mothertongue" value="" class="wpcf7-text application_form_input" size="40"></span>
                  </td>
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<tr>
<td valign="top">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;e] Languages which you can read, write and speak</td>
<td valign="top">
                    <span class="wpcf7-form-control-wrap language"><input type="text" name="language" value="" class="wpcf7-text application_form_input" size="40"></span>
                  </td>
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<tr>
<td valign="top">12. Are You – </td>
<td valign="top">&nbsp;</td>
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<tr>
<td valign="top">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;a] A citizen of Indian Union? If not mention nationality</td>
<td valign="top">
                    <span class="wpcf7-form-control-wrap nationality"><input type="text" name="nationality" value="" class="wpcf7-text application_form_input" size="40"></span>
                  </td>
</tr>
<tr>
<td valign="top">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;b] Native of Karnataka State? If not, to which state do you &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;belong?</td>
<td valign="top">
                    <span class="wpcf7-form-control-wrap state"><input type="text" name="state" value="" class="wpcf7-text application_form_input" size="40"></span>
                  </td>
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<td valign="top">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;c] Have you applied to the Mangalore University for Eligibility &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Certificate?</td>
<td valign="top">
                    <span class="wpcf7-form-control-wrap eligibilitycertificate"><span class="wpcf7-radio application_form_input"><span class="wpcf7-list-item"><input type="radio" name="eligibilitycertificate" value="Yes" checked="checked">&nbsp;<span class="wpcf7-list-item-label">Yes</span></span><span class="wpcf7-list-item"><input type="radio" name="eligibilitycertificate" value="No">&nbsp;<span class="wpcf7-list-item-label">No</span></span></span></span>
                  </td>
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<td valign="top" colspan="2">13. Academic Particulars</td>
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<table border="1" cellpadding="0" cellspacing="0" width="550" bordercolor="#CCCCCC" bordercolordark="#FFFFFF">
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                        <td align="left" valign="top">
                            <div align="center"><b>Exam Passed </b></div>
                        </td>
                        <td align="left" valign="top">
                            <div align="center"><b>Name and Address of the School / College</b></div>
                        </td>
                        <td align="left" valign="top">
                            <div align="center"><b>Name of the Board / University</b></div>
                        </td>
                        <td align="left" valign="top">
                            <div align="center"><b>Percentage and class in which passed </b></div>
                        </td>
                        <td align="left" valign="top">
                            <div align="center"><b>No. of attempts for passing </b></div>
                        </td>
                        <td align="left" valign="top">
                            <div align="center"><b>Year of Passing</b></div>
                        </td>
                    </tr>
                    <tr>
                        <td valign="top" align="left"> a) SSLC /&nbsp; Matric
                        </td>
                        <td valign="middle" align="center">
                            <span class="wpcf7-form-control-wrap NameOfSchoolsslc">
                                <input type="text" name="NameOfSchoolsslc" value="" class="wpcf7-text application_form_input_acedemic" size="15">
                            </span>
                        </td>
                        <td valign="middle" align="center">
                            <span class="wpcf7-form-control-wrap Boardsslc">
                                <input type="text" name="Boardsslc" value="" class="wpcf7-text application_form_input_acedemic" size="15">
                            </span>
                        </td>
                        <td valign="middle" align="center">
                            <span class="wpcf7-form-control-wrap sslcpercentage">
                                <input type="text" name="sslcpercentage" value="" class="wpcf7-text application_form_input_acedemic" size="3">
                            </span>
                        </td>
                        <td valign="middle" align="center">
                            <span class="wpcf7-form-control-wrap sslcattempts">
                                <input type="text" name="sslcattempts" value="" class="wpcf7-text application_form_input_acedemic" size="3">
                            </span>
                        </td>
                        <td valign="middle" align="center">
                            <span class="wpcf7-form-control-wrap yearofpassingsslc">
                                <input type="text" name="yearofpassingsslc" value="" class="wpcf7-text application_form_input_acedemic" size="5">
                            </span>
                        </td>
                    </tr>
                    <tr>
                        <td valign="top" align="left">b) PUC /&nbsp; (10+2) or&nbsp; Equivalent Examination</td>
                        <td valign="middle" align="center">
                            <span class="wpcf7-form-control-wrap NameOfSchoolpuc">
                                <input type="text" name="NameOfSchoolpuc" value="" class="wpcf7-text application_form_input_acedemic" size="15">
                            </span>
                        </td>
                        <td valign="middle" align="center">
                            <span class="wpcf7-form-control-wrap Boardpuc">
                                <input type="text" name="Boardpuc" value="" class="wpcf7-text application_form_input_acedemic" size="15">
                            </span>
                        </td>
                        <td valign="middle" align="center">
                            <span class="wpcf7-form-control-wrap pucpercentage">
                                <input type="text" name="pucpercentage" value="" class="wpcf7-text application_form_input_acedemic" size="3">
                            </span>
                        </td>
                        <td valign="middle" align="center">
                            <span class="wpcf7-form-control-wrap pucattempts">
                                <input type="text" name="pucattempts" value="" class="wpcf7-text application_form_input_acedemic" size="3">
                            </span>
                        </td>
                        <td valign="middle" align="center">
                            <span class="wpcf7-form-control-wrap yearofpassingpuc">
                                <input type="text" name="yearofpassingpuc" value="" class="wpcf7-text application_form_input_acedemic" size="5">
                            </span>
                        </td>
                    </tr>
                    <tr>
                        <td valign="top" align="left">c) Any other Examination
                        </td>
                        <td valign="middle" align="center">
                            <span class="wpcf7-form-control-wrap NameOfSchooldegree">
                                <input type="text" name="NameOfSchooldegree" value="" class="wpcf7-text application_form_input_acedemic" size="15">
                            </span>
                        </td>
                        <td valign="middle" align="center">
                            <span class="wpcf7-form-control-wrap Boarddegree">
                                <input type="text" name="Boarddegree" value="" class="wpcf7-text application_form_input_acedemic" size="15">
                            </span>
                        </td>
                        <td valign="middle" align="center">
                            <span class="wpcf7-form-control-wrap degreepercentage">
                                <input type="text" name="degreepercentage" value="" class="wpcf7-text application_form_input_acedemic" size="3">
                            </span>
                        </td>
                        <td valign="middle" align="center">
                            <span class="wpcf7-form-control-wrap degreeattempts">
                                <input type="text" name="degreeattempts" value="" class="wpcf7-text application_form_input_acedemic" size="3">
                            </span>
                        </td>
                        <td valign="middle" align="center">
                            <span class="wpcf7-form-control-wrap yearofpassingdegree">
                                <input type="text" name="yearofpassingdegree" value="" class="wpcf7-text application_form_input_acedemic" size="5">
                            </span>
                        </td>
                    </tr>
                </tbody>
            </table>
<p style="font-family:Verdana, Geneva, sans-serif;font-size:11px;color:#000;margin-top:0px">14.Total marks obtained and percentage of marks secured in aggregate of Physics, Chemistry & Biology upto two decimal Points including Practical Marks. </p>
<div style="height: 68px;">
<div style="margin-left: 43px;float: left;">Marks <span class="wpcf7-form-control-wrap m"><input type="text" name="m" value="" class="wpcf7-text application_form_inpu" size="4"></span> out of <span class="wpcf7-form-control-wrap o"><input type="text" name="o" value="" class="wpcf7-text application_form_inpu" size="4"></span></div>
<div style="margin-left: 360px;margin-top: 42px; position:absolute;">Aggregate Percentage </div>
<div><span class="wpcf7-form-control-wrap toalmarks"><input type="text" name="toalmarks" value="" class="wpcf7-text application_form_in" size="4"></span> </div>
</div>
<hr style="margin-left:-23px;">
<table cellspacing="0" cellpadding="4" border="0" width="574">
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<td>15.Professional Experience if any</td>
<td>
                    <span class="wpcf7-form-control-wrap experience"><input type="text" name="experience" value="" class="wpcf7-text application_form_input" size="4"></span>
                  </td>
</tr>
<tr>
<td>16. Hobbies </td>
<td>
                    <span class="wpcf7-form-control-wrap hobbies"><input type="text" name="hobbies" value="" class="wpcf7-text application_form_input" size="40"></span>
                  </td>
</tr>
<tr>
<td>17. Games / Sports </td>
<td>
                    <span class="wpcf7-form-control-wrap sports"><input type="text" name="sports" value="" class="wpcf7-text application_form_input" size="40"></span>
                  </td>
</tr>
<tr>
<td valign="top">18. List any outstanding performance medals / certificates received.</td>
<td valign="top">
                    <span class="wpcf7-form-control-wrap performance-medals"><textarea name="performance-medals" class="wpcf7-validates-as-required application_form_input" cols="31" rows="4"></textarea></span>
                  </td>
</tr>
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<td colspan="2">&nbsp; </td>
</tr>
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<td colspan="2">
<div align="center">
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<td>&nbsp;</td>
<td>&nbsp;</td>
</tr>
<tr>
<td>
                            <input type="submit" value="Send" class="wpcf7-submit butnSub" style="background-color:#045954 !important; ">
                          </td>
<td>
                            <input class="butnRest" type="reset" style="background-color:#045954 !important; ">
                          </td>
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</tbody>
</table>
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