5/8/2014 Allen Career Institute - Application Form Acknowledgement & Declaration

http://allen.ac.in/apps/appForms1415/declaration.asp 1/1
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Application Form Acknowledgement (Session 2014-2015)

Application Form No.: 14085656

Photograph
Name of Appl i cant: ANSHUL CHOUDHARY

Father's Name: MR. MOHAN CHOUDHARY
Gender: FEMALE
Medi um: ENGLISH
Center Name: JAIPUR
Stream: JEE (MAIN + ADVANCED) CLASSROOM CONTACT COURSES
Course Name / Course Code: NURTURE COURSE PHASE-III / 1003
Declaration
I hereby declare
1. that I am seeki ng admi ssi on i n my own i nterest and accord.
2. that I shal l be ful l y responsi bl e for any acci dent / mi s-happeni ng occurri ng wi th me/by me i nsi de / outsi de the i nsti tute's premi ses and i nsti tute wi l l not responsi bl e i n any manner.
3. that I shal l be responsi bl e for my rusti cati on on grounds of mi sconduct, mi suse of mobi l e phones, mi suse of i nternet or any i l l egal and i ndecent acti vi ty.
4. that i n case of my sel ecti on i n Medi cal / Engi neeri ng Entrance Exams, the i nsti tute reserves the ri ght to use my name , photo and other i nformati on for publ i ci ty purpose.
5. that I sol emnl y affi rm that the i nsti tute has ri ghts to send me emai l s (e-newsl etters), sms al erts and post on the menti oned communi cati on detai l s.
6. that al l the i nformati on furni shed by me i n the ONLINE Appl i cati on Form or i n any other form etc. i s correct to the best of my knowl edge. I understand that i n the event of any i nformati on
found to be i ncorrect or fal se, my admi ssi on may be cancel l ed wi thout any refund of fee.
7. that I have read al l the i nstructi ons of the Informati on Bul l eti n / avai l abl e Onl i ne and I do agree to fol l ow the i nstructi ons as appl i cabl e.
8. that I agree to abi de by the Refund Rul es of the Insti tute.
9. I knew that al l di spute are subj ect to kota (Raj asthan) j uri sdi cti on onl y


Si gnature of Candi date Date: Si gnature of Father / Mother