Tata-Dhan Academy

T. Malaipatti, Thenkarai PO, Mullipallam SO, Sholavandan (Via), Vadipatti Taluk, Madurai 625 207, Tamil Nadu

Ph.: (04543) 293405, 293406; Fax: (0452) 2602247; email: admissions.tda@dhan.org, tatadhancademy@dhan.org

Application for Post Graduate Diploma in Community Health (PGDCH): 2017-2019

Instructions

  • All fields are compulsory. 
  • Don't leave any box/column blank unless specified as optional.
  • On receipt of the DD for Rs 500/- drawn in favour of Tata-Dhan Academy, payable at Madurai along with two self-attested photographs, we will issue admit card after scruitinising your application. 
  • Please mention your name and online application number given to you (on submission of this form) clearly on the reverse side of the DD and photographs.
  • Last date for application submission: June 05, 2017.
 

1. Name:

Permanent Address

Pincode:

Telephone No. (Residence) with STD code:

Mobile No:

Email:

Mailing Address (Same as permanent address)

Pincode:

Telephone No. (Residence) with STD code:

Mobile No:

Email:

2. Personal Details

Date of Birth : - -

Age: (As on 30th June, 2017)

Marital Status:

Are you a first graduate from your family?

If available,

Voter ID No.:    

Aadhaar No.:    

Bank A/c. No.:  

Bank & Branch:

3. Registration Fee : Rs.500

Demand Draft of Rs.500/- in favour of "Tata-Dhan Academy", payable at Madurai.
Demand Draft    
       DD No.:    
        DD Date :    
        Bank & Branch    
Bank Deposit /Transfer   
        Date of Deposit/Transfer :
       Universal Transaction Reference Number  
        (UTR No.) :                    

Demand Draft of Rs.500/- in favour of "Tata-Dhan Academy", payable at Madurai.

OR

Fee to be deposited/transferred to

Account Name : Tata-Dhan Academy
Account No.: 601701014896
IFS Code: ICIC0006017
Bank & Branch : ICICI Bank, Kochadai Branch, Madurai.

4. Education
Qualification Nameof the School/College/University and location Month & Year Marks/OGPA Obtained Percentage of Marks
From To
Secondary School (10th)

(mm-yyyy)

(mm-yyyy)

%
Higher Secondary School (10-12)

(mm-yyyy)

(mm-yyyy)

%

Bachelor's Degree in

(mm-yyyy)

(mm-yyyy)

%

Master's Degree in

(if applicable)

(mm-yyyy) (mm-yyyy) %

5. Work Experience (if applicable - fill in only as many rows as required)
Date Employer's Name & Location Job Title Nature of Job
From To

(mm-yyyy)

(mm-yyyy)

(mm-yyyy)

(mm-yyyy)

(mm-yyyy)

(mm-yyyy)

(mm-yyyy)

(mm-yyyy)

(mm-yyyy)

(mm-yyyy)


6. Extra Curricular Activities (optional)

7. Languages Known 8. How did you come to know about this programme?
(Check at least one box)

Speak

Read

Write

Website  

Friends

Seniors

Poster

College/Faculty

Others  

9.Selection(GD/Personal Interview Center, Please Choose only three and write your preference as 1,2 and 3 and right side of place)

Chennai  

Madurai  

Bengaluru  

Hyderabad  

Mumbai  

Bhubaneshwar  

Lucknow  

Guwahati  

Bhopal  




10 Write about yourself and your family. (Not less than 300 words)


11. What is your ambition in the next five years? (Not less than 300 words)


12. Why do you want to pursue the course (Not less than 300 words)


13. What do you know about Tata-Dhan Academy? How did you come to understand about the Academy?



14. Declaration

I hereby confirm to the best of my knowledge, the information I have provided in this application is complete and true.