Registration Form - Lotus Bausch & Lomb Institute of Optometry

1. Name of the Candidate * As entered in the Higher Secondary certificate

2. Gender *

3. Date of Birth *

College

Name of the Course *

(The candidate should have completed 17 Years of age at the time of admission or should complete the age on or before 31st December of the year of admission)

Aadhaar No. *

Nationality *

State *

Name of the Religion *

Community *

Blood Group *

Willingness to donate blood *

Student’s E-mail *

Student’s Mobile No. *

Father’s/Guardian’s Email

Father’s Name *

Mother’s Name

Guardian’s Name

Occupation of the Father/Guardian *

Name of the Organisation *

Designation *

Father’s/Guardian’s Annual Income *

Occupation of Mother

Name of the Organisation

Designation

Mother’s Annual Income

Communication Address *

Land mark *

Pin Code *

Mobile No. *

Communication address and present address same

1. Qualification and marks obtained (original mark sheet to be enclosed)

Name of the course	Name of the Board (State / Central/Others)	University / College	Duration Of the Course	Register No.	Month / Year of Passing

A . Hsc Certificate

Subject	Tamil/ Other	English	Maths	Physics	Chemistry	Botany	Zoology	Biology	Total
Maximum Marks
Marks Obtained

2. 10th Certificate

Subject	Tamil	English	Maths	Science	Social science	Botany	Zoology	Biology	Total
Maximum Marks
Marks Obtained

1. FOR CANDIDATES WHO HAVE PASSED THE QUALIFYING EXAMINATION OTHER THAN H.S.C. OF TAMILNADU

Photo of the Student Maximum upload file size 2MB. Allowed file types jpeg, jpg, png.

Signature of the Student Maximum upload file size 2MB. Allowed file types jpeg, jpg, png.

10th marksheet Maximum upload file size 2MB. Allowed file types jpeg, jpg, png.

HSC marksheet Maximum upload file size 2MB. Allowed file types jpeg, jpg, png.

Aadhar certificate Maximum upload file size 2MB. Allowed file types jpeg, jpg, png.

Photo of the Father Maximum upload file size 2MB. Allowed file types jpeg, jpg, png.

Photo of the Mother Maximum upload file size 2MB. Allowed file types jpeg, jpg, png.

Signature of the Parent Maximum upload file size 2MB. Allowed file types jpeg, jpg, png.

Photo of the Guardian’s Maximum upload file size 2MB. Allowed file types jpeg, jpg, png.

Signature of the Guardian’s Maximum upload file size 2MB. Allowed file types jpeg, jpg, png.

Transfer Certificate Maximum upload file size 2MB. Allowed file types jpeg, jpg, png.

I declare that the particulars mentioned above are true and I will not claim/ ask for any change with regard to any of the particulars furnished above.
I agree to abide by the rules and regulations of the College/ University as framed from time to time. Thus, I hereby express my written consent to perform my Internship duties at any Lotus Eye Hospital branch and to acquiescing to the management's assigned posting rotations. I submit my Aadhaar number and voluntarily give my consent to..