1. Sree Uthradom Thirunal Academy of Medical Sciences
(Recognized by Medical Council of India & Govt. of India and affiliated to Kerala University of Health Sciences, Thrissur)
Sponsored by: MOOGAMBIGAI CHARITABLE AND EDUCATIONAL TRUST
Vencode -P.O, Vattappara, Thiruvananthapuram – 695 028
APPLICATION FOR ADMISSION TO MBBS, 2021-22
NOTE:
1.Use only “BLOCK LETTERS” to fill in the application form
2.Fill in every column without fail and attach document in proof there of
1 Name of applicant(as in School Record)
2 Age and Date of Birth Age Date Month Year
3 Sex(Tick the appropriate column) Male Female
4 Nationality
5 Name, occupation and official address of
Father
Mother
Phone Number
6 Address to which communication to be sent with PIN
code
Contact Telephone / Mobile Number/Email.ID
Aadhar No: Blood Group:
7 Caste, Religion and Community
9 A. Name of institution last studied
B. Name of qualifying examination passed
C. Register No.& Year of Passing
D. Whether eligible for higher studies
Affix recent
passport size
photo graph of
the applicant

2. 10 Marks obtained at the qualifying examination
Subject Maximum Marks Marks Secured % of marks
Part I English
Part II Additional Language
(...........................................)
Part III Optional Subjects
1.Physics
2.Chemistry
3.Biology
4.Mathemetics
5. ...............................
Total Marks
11 Details at Entrance Exam Application No. Reg. No. Roll No. Overall Rank Category Rank/State Rank
KEAM, 2021
NEET, 2021
NEET Score/Percentile
12 Additional information/
details, if any
13 Name , Occupation , address
and contact No. of Local
guardian ( In case of Outside
state
Declaration by the applicant and parent
We, the applicant and the parent of the applicant do hereby solemnly affirm that the statements made and
information furnished above and also in all the enclosures thereto submitted are true to best of our knowledge, belief and
understanding. We declare that, the applicant will, if admitted, abide by the stipulations in the prospectus, code of
conduct and rules and regulations of SUT Academy of Medical Sciences, Thiruvananthapuram..
Station : Signature of the applicant :
Date : Name :
Station : Signature of the parent :
Date : Name :