EMBASSY OF INDIA Data Sheet No.

(for Office Use )

KATHMANDU
Note : 1. Data Sheets are to be submitted in Five Copies along with required enclosures.
2. Before filling this Form, read the instructions carefully. All entries should be made in Capital Letters.

(i) Choice of Examination Centre (Kathmandu or Birgunj)

Please write one center only in the box
Î

(ii) Out of the six courses given below, choose only two courses and
indicate in the box. More than two course are not allowed. Î COURSE – I

1. MBBS [SFS] 4. B.VSc [Scholarship]

2. BE [Scholarship] 5. B Sc Ag. [Scholarship]
COURSE – II
3. B.Pharma [Scholarship] 6. B.Sc Dairy Tech. (Scholarship)

Choice – I Choice – II Choice - III

(iii) If opting for BE, indicate preferred
branch of Engineering Î

1. Candidate's Name (in capital letters) (please keep one box blank between name, middle name & sur name)

2. Father's Name (in capital letters) [ Father’s Occupation: ___________________________________________]

3. Mother’s Name (in capital letters) [ Mother’s Occupation: ___________________________________________]

4. Date of Birth
a. In Christian Era b. In Birkram Samwat c. Age as on 1st July, 2009

DAY MONTH YEAR DAY MONTH YEAR YEAR MONTH DAY

5. Correspondence Address (in capital letters in English) Signature of Candidate È

Name :
Father’s Name :
Address :
:
District : Please affix recent
passport size
Photograph

6. Write your Permanent District Î

(In the box in Capital letters )
7. Permanent Address
___________________________________________
___________________________________________
District : ___________________________________
8. Details of Nepalese Citizenship
(Please attach photocopy)
a. Citizenship No : __________________________
b. Issuing Date : __________________________

Telephone with code:_________________________ c. Place of Issue : __________________________

Email Address: ______________________________

9. (i) Educational Qualification with name of Institute and year of passing

(Please attach attested photocopies of mark sheets and Fill the column as applicable otherwise keep blank)

Name of Examination Year of Institute AGGREGATE MARKS

Passing Total Marks Marks Obtained %age of marks

Class – XI

Class – XII
(If appearing, keep the columns
blank and write “Appearing”)

(ii) Percentage of Marks (wherever applicable)

Name of Examination % age in PCM % age in PCB % age in English

Class – XI

Class – XII (If appearing, keep the

columns blank and write “Appearing”)

10. Details of any other scholarships received previously from Embassy of India or any other Organization:

___________________________________________________________________________________________

___________________________________________________________________________________________

DECLARATION TO BE SIGNED BY THE CANDIDATE

I hereby certify and declare that:

I certify that information / details furnished in the above data-sheet is correct to the best of my
knowledge and belief. I am also aware that my application will be rejected if any fact stated above
is found to be incorrect. I have also understood the terms and conditions mentioned in the notice
and I would abide by the same

DATE: ____________________
___________________
PLACE: ____________________ Signature of Candidate