COMMON ENTRANCE APPLICATION - JUNE 2013

Programme : UG

Personal Details

Application No : 027465

Name of the Candidate as in the X std

certificate (in Capital letters)
Parent's / Guardian's Name
Gender
Date of Birth
Age
Parent's / Guardian's Occupation
Parent's Educational Background
Annual Income
Religion
Category
Nationality
Mother Tongue
Differently abled

: AYUSH JINDAL
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RAKESH KUMAR
Male
29-05-1995
18
Business
Both Graduates
One lakh to four lakh fifty thousand
HINDU
General
Indian
Hindi
No

Address For Communication

Email
Address Line 1
Address Line 2
Address Line 3
City
State

: ayush.jindal95@gmail.com
: 93, SARASWATI MANDIR
: SURAJ KUND ROAD
: MEERUT
: MEERUT
: UTTAR PRADESH

Pincode
Country
Telephone Number
(with STD code)
Mobile
Territory Code

: 250002
: INDIA
:: 9358431137
: Urban

Qualifying Examination Details

Course
X Std
XII Std

Year of
Passing
2011
2012

Physics

Chemistry

70

72

Main Subject Marks

Maths
English Overall (%)

92

95
66

95
73

Grade
A1
+1

Name of the Board

/ University
CENTRAL BOARD OF SECONDARY EDUCATION
CENTRAL BOARD OF SECONDARY EDUCATION

Highest Percentage of marks obtained : X Std - 95 %

Preferred Choice of Courses

1st Preference
2nd Preference

: B.Tech Marine Engineering

: BSc Nautical Science

3rd Preference

: DNS leading to BSc Nautical Science

Preferred Choice of Exam Centres

Preference

: N002 - Delhi - Applied Research International School of Maritime Studies

Payment Details - Offline

Bank Name
Payment Date

: STATE BANK OF INDIA

: 03-05-2013

Journal / Transcation Number : 17673748

Amount
: 1030.00

Declaration by the Applicant

I AYUSH JINDAL hereby declare that all the particulars stated in this application and enclosures, if any, are true to the best of my knowledge and belief. I
have read the Information Brochure and I shall abide by the terms and conditions therein. In the event of suppression or distortion of any fact like category,
educational qualifications, nationality etc., made in my application form, I understand that I will be denied admission and if already admitted, my
admission/degree acquired is liable for cancellation. I also understand that the decision of the Admission Board regarding my admission for DNS/
B.Sc.(Nautical Science) / B.Sc. (Maritime Science) / B.Sc. (Ship Building and Repair) / B.Tech (Marine Engineering) / B.Tech (Naval Architecture & Ocean
Engineering) / M.Tech (Naval Architecture & Ocean Engineering) / M.Tech (Dredging & Harbour) / MBA(PSM)/MBA (ITL)/ LLM/ PGDME Degree Course is final
and I shall abide by the decision. Further, if admitted I promise to abide by the rules and norms of discipline of the Institute I join.

Place : _____________________
Date : ______________________

RAKESH KUMAR
( Name of the Parent's / Guardian's )

(Signature of Applicant)

(Counter Signature of the Parent's / Guardian's)