Personal Details
Student ID: 14
Full Name: ganesh
Gender: M
Date of Birth: 2000-08-11
Nationality: indian
Demand Draft Details
Draft Number: 234562
Date of Issue: 2000-06-12
Amount (In US Dollars): 4350
Issuing Bank: american bank
Bank Transfer Details (Indicate Date of Bank Transfer details in the column given below and attach the copy of the same with the printed version of this form) :
Name, Relationship and Address of Parents/ Guardian
Name of Parent/ Guardian: shiva
Indicate Relationship: father
Contact Address (Abroad and in India)
Abroad In India( if any)
Address abc
City/ Country aca
Pin Code 12444312
Phone/ Mobile No.(along with country/ area code) 89764323
Fax No. (with country/ area code)
Email (must specify)
[email protected]Details of Qualifying Examination
Name of the Name of School/ Place of the School & Name of Board / Month & Year in which Medium of Instruction in
Examination College Country University Passed Qualifying Exam
ass sdd dss qwwq asd das
Marks in Qualifying Examination
Subject Marks Obtained Maximum Marks Subject Marks Obtained Maximum Marks
Physics 24.00 34.00 English 23.00 34.00
Chemistry 12.00 34.00 Others 33.00 33.00
Mathematics 34.00 34.00 Others 22.00 43.00
Particulars of the Passport: (Copy to be enclosed)
Passport Number: 3423f
Place of Issue: fa
Country of Issue: werr
Date of Issue: 2000-12-07
Valid upto: 2001-01-26
Course Choices:
Sl. No Institute Course
1 MANIT, Bhopal Electronics and Communication Engineering
2 SVNIT, Surat Electronics and Communication Engineering
3 MANIT, Bhopal Information Technology
4 IIIT Allahabad - Main Campus Electronics and Communication Engineering
5 IIIT Allahabad - Main Campus Information Technology
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Particulars of Study Abroad (Applicable for Indian Nationals only)
Number of years you had education abroad during the last 6 years: 4
Please choose appropriate standard / class you had studied / are studying abroad during the last 6 years.
10,11,12 Classes
Name of the country from which qualifying exam has been passed / appeared: aus
Declaration by the Applicant:
I Mr./ Ms. ________________________________ hereby declare that all the particulars stated in the application and enclosures are true to the best of my
knowledge and belief. I have read the Guidelines and I shall abide by the terms and conditions therein. I understand that my admission will be provisional
and in the event of my being found ineligible at a later date, I will be denied admission and, if already admitted, my admission will be cancelled. I also
understand that in all matters concerning admission, the decision of the appointing agency is final and I shall abide by it.
If selected, I promise to abide by the rules including those of accommodation and code of discipline of the Institute I join.
Place:______________________ Date:________________________
Signature of Applicant:_______________________
Declaration by Parent/ Guardian:
Mr./ Ms._________________________________________ is my son / daughter / ward being admitted. I Mr./
Ms.________________________________________________ hereby give an undertaking to py regularly all his/ her dues to the Institute and to the hall of
Residence/ Hostel till the completion of his/ her course of studies. I also undertake the responsibility for his/ her good conduct.
Place:______________________ Date:________________________
Signature of Parent/ Guardian:_______________________
