Note:- Before filling up this form, please read carefully the detailed instructions for STS 2017
LOGIN DETAILS
Student's complete email id *
(This will be the LOGIN ID for future use)
Retype complete email id *
Mobile *
(This will be used for future correspondence)
Alternate email id
Dental/ paramedical/ non-medical/ any other courses students are not eligible
STUDENT COURSE DETAILS
Full Name *
(Please do not write your name in ALL CAPS)
Title First Name Middle Name Last Name
Date of joining MBBS Course *
State (College Belongs to) *
Class *

Name of the College *   
Address Line 1*
Adddress Line 2
City *
Pin Code *
College Telephone
STD Code Tel Ph If,Extn

STUDENT PERSONAL DETAILS
Gender *
Nationality *

Date of Birth *
State (Home Belongs to) *
Home Address Line1 *
Home Address Line2
City *
Pin Code *
Alternate Mobile
Residence Telephone
STD Code Tel Ph
Where would you want correspondence to be sent to*