Form No:
MIP College Of Physiotherapy
Vishwanathpuram, Ambajogai road, Latur-413521
Ph. (02382)228135, Fax:(02382) 228939, 227146,
Application Form

*First Name :
*Surname :
*Father's / Guardian's Name :
*Father's / Guardian's Occupation :
*Communication Address : *City/Village :
*Post office :
*State :
*Pin Code : *Tel(with STD Code) :
*Mobile : *E-mail :
*Permanent Address *City/Village :
*Post office :
*State :
*Pin Code : *Tel(with STD Code) :
*Mobile :*E-mail :
*Institution Last Studied & Place Of The Institution
*Marks obtained in SSLC/10th *Out Of Total Marks:
*Aggregate % in SSLC
*Marks obtained in PUC||/12th *Out Of Total Marks:
*Aggregate % in PUC

*CET/asso. CET Rank/Marks
Other Entrance Details
*Mother Tongue
*Spoken Language
*Please Attach The Following Certificates:
  1. 3 Copies of 10th Marks Card
  2. 3 Copies of 12th/PUC Marks Card
  3. 3 Copies of Transfer Certificate
  4. 3 Copies of Migration Certificate

I the undersigned, affirm that the information furnished above is correct to the best of my knowledge and belief, and that I will accept as final and binding the decision of MIP, regarding my admission to the program. If any information provided by me is found to be incorrect at a later date, MIP is authorized to take any action against me that it deems fit, including legal action. I hold myself responsible for all the dues and prompt payment of fees, If selected. I have noted that fees once paid are not refundable under any circumstances except as per the rules of Institute. I have gone through admission rules and regulations of the Institute and understood them.

I Agree     I Disagree