A. J. Institute of Hospital Management

(A Unit of Laxmi Memorial Education Trust ®)

A. J. Hospital & Research Centre Campus

Kuntikana, Mangalore - 575 004.

Application for Admission to

Master of Hospital Administration (MHA)

For the Year

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Click on Image to Upload Photo *

Part 1 - Personal Details

1. Name of the Candidate *

(To be entered in Block Letters as found in the SSLC Marks Card)

2. Date of Birth *

(as entered in the SSLC marks card)

3. Gender *

Male

Female

Mother Tongue *

4. Name of the Father / Guardian *

5. Occupation of Father / Guardian *

6. Annual Income of Father / Guardian *

7. Religion *

Caste *

8. Community *

OBC

Others

9. Nationality *

Indian

NRI

Foreign

10. Permanent Address *

Telephone No.

Mobile No. *

Telephone No.

Mobile No.

12. Emergency Contact *

13. Languages which you can read, write and speak *

Part 2 - Academic Particulars

Exam Passed	Name & Address of the School / College	Name of the Board / University	Class Obtained	Percentage of Marks	Year of Passing

Part 3 - Documents Required

(Please Tick the relevant box whichever applicable for which the copy of the documents is enclosed along with this application)

10th Marks Card / PUC

All Degree Marks Card

Transfer Certificate / Conduct

Date of Birth Certificate

Provisional Degree Certificate

Convocation

Migration Certificate

Eligibility Certificate from RGUHS N

Nationality Certificate (Applicable only for International Student)

Nursing Experience Certificate for Nursing Students

Photos - 15

Nursing Registration Certificate for Nursing Students

Other

Part 4 - Student Declaration

I agree to abide rule and regulations of the A. J. Institute of Hospital Management
I acknowledge that if I am accepted for a course of study I am liable to pay the fees for the full term and it will not be refunded under any circumstances.
I am aware that 75% attendance is mandatory in all subjects for a student to be eligible to appear for the university Examinations.
I am aware that consumption of alcohol and smoking is prohibited in the college and I agree to abide by this condition failing which necessary disciplinary action can be taken against me.
I hereby agree that I will not cause any damage to the college property; I accept that failure on my part to abide by this policy may lead to necessary disciplinary action and any related costs incurred by my actions will be recovered from me.
I am aware that delay in payment of the fees attracts a late fee (fine) until such time I have paid the same.
I agree that it is an essential term of my agreement with AJIHM that information I have given in this form and any attached documents is true and complete and I acknowledged that AJIHM may suspend my enrolment if false information has been given.

Admission