Application No: NATIONAL INSTITUTE OF SPEECH & HEARING, THIRUVANANTHAPURAM Karimanal PO, Akkulam, Thiruvananthapuram – 695583 Email - [email protected]. Website: www.nish.ac.in. Application for Admission to Post Graduate Certificate Course in Auditory Verbal Therapy (PGCAVT) 2014-2015 NB: Kindly read the prospectus before filling up the application form. Personal Details Name of applicant (In Block Letters): Expansion of Initials: Date of Birth (DD/ MM/ YYYY): Sex: Mother tongue: Name of Parent/ Guardian: Occupation of Parent/ Guardian: Are you an Indian citizen of Kerala Origin? : If no, provide details: Religion: Caste: Caste Category: Physically handicapped: Yes/No Contact Details Telephone: Mobile: Email: Permanent Address (In Block Letters): District: State: Country: Pin: Mailing Address (In Block Letters): District: State: Country: Pin: Academic Details Details of Qualifying Examination: Please tick appropriate: MASLP / BASLP / B.Ed. (HI) / DTYHI Institution where last studied with Year of study: Name of the Board/ University: Years of Experience: Marks Obtained for Qualifying Exam Qualifying Exam Payment Details Bank Txn Journal No: Challan Amount: Payment Date: Marks Obtained Maximum marks % of Marks Declaration I,....................................................................... hereby certify that the details given in the application form are correct. I do hereby declare that, if I am admitted, I shall abide by the rules and regulations of the Institute and will not involve in any activity that may be detrimental to the orderly working and discipline of the Institute. Place : Date : Signature of the Applicant I, …………………………………………………solemnly declare that all facts furnished in the application form for the admission of my daughter/ son/ ward.......................................... are true to the best of my knowledge and belief. I undertake that he/ she will abide by the rules and regulations of the Institute. Place : Date : Signature of the Parent/Guardian Name of the Parent/ Guardian ……………………………….. For Office Use Admitted on ………………………………………… Admission No: …………………………………………..... Course to which admitted …………………………………………………. Certificates verified by (1) (2)