Master of Optometry (M.Optom) - The Sankara Nethralaya Academy

The Sankara Nethralaya Academy
(A Unit of Medical Research Foundation)
No.9, Vanagaram Road, Ayanambakkam , Chennai – 600 095
Tel : 044 4908 6000 www.thesnacademy.ac.in
APPLICATION FORM FOR POST-GRADUATE COURSES
Application No.
Course Applied for (Please tick any one)
Post Graduate Courses
Students
Recent Photograph
MHA (Master of Hospital Administration)
MBA (Hospital and Healthcare Management)
M.Sc. (Medical Laboratory Technology)
M.Optom. (Master of Optometry)
Name of the Applicant with initial (as in Qualifying Certificate – in BLOCK letters):
Expansion of Initials
Gender
Male
Date of Birth: Date:
Female
Month:
Address for Communication:
Year:
Neutral
Place of Birth
Nationality:
Blood Group :
Pin Code:
E-mail ID:
Phone with STD Code:
Mobile No.:
Parent Name:
Name of Guardian (If student not staying with parents):
Parent/Guardian Address for Communication (If different from above):
Pin Code:
E-mail ID:
Phone with STD Code:
Mobile No.:
Details of Educational Qualifications:
Course Studied
Major
Subjects
Month & Year
of Passing
Name of the
School / College /
University
Medium
Aggregate %
Marks /Class
SSLC/10th Std
Hr.Sec/12th Std
Under
Graduate
Post Graduate
(Enclose Attested copies of SSLC/Hr. Secondary certificates and Degree Certificates or UG Provisional
Certificates).
Eligibility Certificate Details (For Candidates with qualifying exam from other than Tamil Nadu)
Certificate No.:
Date of Issue:
Issuing University:
Issuing Authority:
Migration Certificate Details:
Certificate No.:
Date of Issue:
Issuing Institution:
Issuing Authority:
Transfer Certificate Details:
Certificate No.:
Date of Issue:
Issuing Institution:
Issuing Authority:
Community
Community Certificate Details:
Certificate No.:
Date of Issue:
Issuing Location:
Issuing Authority:
Language Proficiency (Tick appropriately):
Language (Specify) To Speak
To Speak
To Write
Mother Tongue
English
Additional
Have you attended any Education Programme at Sankara Nethralaya?
Course
Attended
Period
From Date
DD
MM
To Date
YY
DD
MM
YY
Additional Participation (courses and programmes attended) if any (Other than the above):
Miscellaneous:
Do you require hostel accommodation?
Yes / No
Do you require transport facility?
Yes / No
Source of funding:
Own / Sponsorship / Scholarship / Bank loan / Others
Note : Separate application to be submitted for scholarships
References:
Payment Details
Registration fee Rs.1000/- (non refundable)
Mode of payment: Cash/Cheque/DD
Cheque / DD No.:
Rs.
Date:
Bank:
Note: Candidate should write his / her name on the reverse of the Cheque / Demand Draft
Declaration
I hereby declare that the particulars given above are true. If any of the particulars furnished are found
to be false, I agree to forfeit my admission without claiming any refund. We assure strict adherence to TSNA's
regulations after admission.
Date:
Place:
Signature of the Candidate
Signature of Parent / Guardian
Enclosures:
Note: Attested photocopies of the following should be enclosed with this application form
1. SSLC, HSSC, Degree Certificates.
2. Community certificate, Transfer certificate, Migration certificate, Eligibility certificate
(as applicable).
3.Photo copies of attainments, if any, in extracurricular activities, and other training undergone.
4.Two passport size photographs (recent).
5.Copy of identification proof.
6.Cheque /DD drawn in favour of “Medical Research Foundation” Payable at Chennai, towards
Registration fees.
Filled in application form along with enclosures to be forwarded to:
The Academic Officer
The Sankara Nethralaya Academy
No.9, Vanagaram - Ambattur Road
Ayanambakkam, Chennai – 600095
Tamil Nadu, India, Ph: 044-4908 6000
Registration Details (To be filled in by TSNA official)
Registration Date
Registration No.:
Remarks:
Registration-in-charge (sign)