Application Registration Form  
APPLICATION FORM
INSTRUCTIONS
a. This application form is common to all candidates seeking admission at AIISH, Mysore, AYJNIHH, Mumbai and AYJNIHH, Kolkata.

b. Please download and read the prospectus and instructions for filling online
application form before filling.

c. DD number is required to fill the application form.

d. After filling this form, click Submit, take a printout and send it to The Director,
All India Institute of Speech &, Hearing,Mysore-570006 / Director, AYJNIHH, Mumbai / Assistant Director, AYJNIHH, Kolkata along with DD and duly filled Admission ticket (in duplicate).
1)
Application No
(Application No. will be given by Institute)

2)
Course Applied for
B. Sc (Speech & Hearing, AIISH)
BASLP (AYJNIHH, Mumbai)
BASLP (AYJNIHH, Kolkata)
 M. Sc (Audiology, AIISH)
M. Sc (Speech-Language Pathology, AIISH)
3)
Preference of Entrance Examination Centre (For courses A, B & C only)
First Choice Mysore     Mumbai     Delhi     Kolkata     Chennai     Guwahati    
Second Choice Mysore     Mumbai     Delhi     Kolkata     Chennai     Guwahati    


4)
Title
Mr.     Mrs.     Ms.    

5)
Name of the Candidate (As given in 10th Std. Marks sheet)


6)
Father's Name OR Guardian's Name(If parents are not alive)


7)
Mother's Name


8)
Date of Birth
9)
Age
Day : Month : Year :


10)
Nationality
Indian    Foreign   

11)
Subjects opted for B.Sc Entrance Exam
Phy    Che    Bio    Mat
12)
Qualifying Examination


13)
Country In which appeared for qualifying examination
India    Foreign   

14)
Postal Address


15)
City


16)
State
17)
Pincode


18)
Telephone Number with STD Code


19)
E-mail(If any)


20)
The Category under which you wish to apply
General Merit
SC
ST
North Eastern States
Foreign
DHA & ET/DHLS
Physically Disabled (Ortho)
OBC

21)
Do you require hostel facility
Yes     No    

22)
Marks obtained in the qualifying examination
A)  (A) Applicants for courses A, B & C: Enter marks of II P.U.C. (10 + 2) Science subjects.

The candidates should fill in the marks obtained in science subjects of the qualifying examination in the
appropriate box provided and in the same order as it appears in the marks card. Only first three letters
of the subjects should be entered. Those who have not received their marksheet need not enter the marks.
  Subject Max.Marks Marks obtained
a
b
c
d
e

      B)  Applicants for all other courses: Enter marks obtained in qualifying examination.
 
Year Total No.Of Papers Max.Marks Marks obtained
1st Year
2nd Year
3rd Year


Details of fees paid
DD No :
DD Date : Day : Month : Year :
Amount :
Bank Name :
Branch Name :


(the student should also fill the format of admission ticket in duplicate and COMPULSORILY send it to us along with the DD. )


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