Admission Form

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First Name

Last Name

Middle Name

Gender

Male Female

Student Photo (1MB or less)

Medical College Details

Date of Birth

Place of Birth

Nationality

E-mail ID

WhatsApp Mobile Number

Address

First Name

Last Name

Middle Name

Mobile

E-mail ID

Profession

Terms & Conditions

1. I agree to make full payment for the programs I enrolled for.
2. I will pay the full amount prior to commencing the program.
3. Programs fees are non-refundable.

Fee details for each program

SuperHIT Bundle - Rs. 1,20,000
SuperHIT (early bird) - Rs. 1,10,000 (subject to approval)

Axis Bank Account number: 920020000918904
Account name: Thirdeye Medical Education
Account type: Current
IFSC Code: UTIB0000047
MICR Code: 395211002

Date

Place

Signature of the Parent/Guardian

Signature of the Student