| 1. (a) |
Name of the Candidate (As per Class XII
Certificate)
|
|
| 1. (b) |
Nationality
|
Indian |
| 2. |
Date of Birth (DD/MM/YYYY), (As per Class X
Certificate) |
01/08/1986 |
| 3. |
Sex : Male / Female |
Female |
| 4.(a) |
Category: SC/ST/OBC/General (If Yes, Pl.
attach proof thereof) |
SC |
| 4.(b) |
Are you suffering from any of the
disabilities (PH/HH/OH) (If Yes, Pl. attach proof thereof) |
Yes |
| 5. Details of Class XII
Examination passed by the Candidate: |
| |
|
| a) Name of the Examination passed: |
AISSCE-2010 |
| b) Roll Number of Sr. School Certificate Exam-2010: |
1200004 |
| c) Year of Passing: |
2010 |
| d) State in which School ( from where done XII) was
located |
|
| e) Total aggregate marks obtained in the examination (in
First five subjects) |
417 |
| f) Stream |
SCIENCE | |
| 6. |
Detail of Parents and their
Income
| |
Mother |
Father |
| a) Name: |
|
|
| b) Employment Status: |
|
|
| c) If working designation/post held (if pensioner write
the post last held): |
|
|
| d) Name of office and address(if pensioner write the name
of last employer) |
|
|
| e) Nature of office (if pensioner nature of the office
from which retired) |
|
|
| f) Pay Scale of the Post (if pensioner write the pay scale
of the post from which retired) |
|
|
| g) Total Annual Income of year ending Mar 2010 (Including
income from business, land, property, interest etc) |
|
| |
| 7. |
Do you fall under Creamy layer as per
instructions contained in DOPT OM No. 36033/5/2004-Estt (Res) dated
14.10.2004. |
No |
| 8. |
Present Address and contact
details |
| a) Address for Correspondence: |
|
| |
|
| |
|
| b) Telephone No. with STD Code: |
|
| c) Mobile No.: |
|
| d) E-mail ID: |
| |
| 9. |
Is the candidate in receipt of any other
scholarship from State Government or other institution or person
? |
Yes
If Yes, particulars should be
given including the monthly rate and date from which the scholarship
is being drawn.
test scholarship recd
|
| 10. |
Name and Address of Institution where
admitted for Graduate degree Course |
| a) Name of the Institution : |
|
| b) Address of the Institution : |
|
| c) Name of the Course : |
|
| d) Subject of the Course : |
UG PROFESSIONAL Duration:Years |
| e) Type of Institution : |
State Govt |
| f) Type of Programme : |
ENGINEERING |
| g) Mode of Study : |
REGULAR |
| h) Pattern of Examination : |
SEMESTER |
| i) Course Approval : |
AICTE | |
| 11. |
Particulars of Savings Bank
Account (Mandatory; Application will be rejected if all the columns
are not filled)
| a) Account Number |
123456789012 |
| b) Name of the Bank |
ALLAHABAD BANK |
| c) Address of the Bank |
BANK ADDR |
| d) RTGS/NEFT Code (11 Digit Code of the Bank) |
00001111111 | |