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Cacee - Application 1 2

The document is an application form for the P.G. Diploma in Developmental Neurology (PGDDN) at the University of Kerala, filled out by Dr. Virender Verma. It includes personal details, educational background, and course fee payment information. The applicant declares the truthfulness of the information provided and includes a signature for verification.

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44 views2 pages

Cacee - Application 1 2

The document is an application form for the P.G. Diploma in Developmental Neurology (PGDDN) at the University of Kerala, filled out by Dr. Virender Verma. It includes personal details, educational background, and course fee payment information. The applicant declares the truthfulness of the information provided and includes a signature for verification.

Uploaded by

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Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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UNIVERSITY OF KERALA Photo

CENTRE FOR ADULT, CONTINUING EDUCATION AND EXTENSION


VIKAS BHAVAN P.O, PMG JN., THIRUVANANTHAPURAM – 695033

APPLICATION FORM FOR CONTINUING EDUCATION COURSES

NAME OF COURSE : P.G. Diploma in Developmental Neurology (PGDDN)

1. a) Name in English ( in block letters ) :


VI R E N D E R V E R M A
b) Name (in Mother Tongue) :
2. Sex : Male

3. Age & Date of Birth : 4 1 2 6 0 1 1 9 8 4

4. Name of Father/Guardian : OM P RAKAS H


(Specify Relation) : Father
5. Marital Status : Married

6. Economic Status :APL


7. Religion and Community : HI N D U

KS H A T R I Y A
8. Address for communication : C/O P R A K A S H CO P Y HOUSE

N E A R: A D A R S H S CH O O L

OPP: R A I L W A Y L I N E S, GANDHI NAGAR

CH AR K H I D A D R I (H A R Y A N A)

Pin 1 2 7 3 0 6
Email. id
vadrenaline@gmail.com
9. Phone No.(with STD Code) : +91- 8 6 5 7 6 5 6 3 4 7 0
.

Mob No. : 9 0 7 0 4 3 7 3 3 3
10. Educational level :
Name of Institution Name of the course Year of Year of Subject Marks
Studied study passing the in %.
examination
PGIMS, ROHTAK MD (PEDIATRICS) 3 YRS 2011 PEDIATRICS 55.63%
(2008-2011)

PGIMS ROHTAK MBBS 5.5 YRS 2005 MBBS 59.06%


(2001-2007)

LNMU, Darbhanga MA (Psychology) 2 yr 2020 PSYCHOLOGY


(2018-2020)

IHMH, Trippur Post Graduate Diploma 1 yr 2018 Child Psychology


(2017-2018)

11. Details of course fee


Sl. Date Name of Bank & Branch INB Ref No. Amount
No.
1
12/03/25 To: SBI , KERALA UNIVERSITY OFFICE CAMPUS IHS9601850 500
From: SBI, Medical college Branch, Rohtak (HR)

DECLARATION
I, DR VIRENDER VERMA , do hereby declare that the
statements made in the application are true and the documents attached herewith are true
copies of the originals in my possession, which will be produced for verification when
required.

Place : CHARKHI DADRI (HARYANA)


Date : 12/03/25 Signature of applicant

OFFICE USE
Admitted / Not admitted

Date : Director

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