Note :

Data Sheet No. (for Office Use )

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 (ii) Out of the six courses given below, choose only two courses and indicate in the box. More than two course are not allowed. 1. 2. 3. MBBS [SFS] BE [Scholarship] B.Pharma [Scholarship] 4. B.VSc [Scholarship] 5. B Sc Ag. [Scholarship] 6. B.Sc Dairy Tech. (Scholarship) Choice – I COURSE – I

COURSE – II Choice – II Choice - III

(iii) If opting for BE, indicate preferred branch of Engineering 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: ___________________________________________]


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










5. Correspondence Address (in capital letters in English) Name Address District : : : :

Signature of Candidate

Father’s Name :

Please affix recent passport size Photograph


Write your Permanent District (In the box in Capital letters )


Permanent Address ___________________________________________ ___________________________________________ District : ___________________________________ Telephone with code:_________________________ Email Address: ______________________________

8. Details of Nepalese Citizenship (Please attach photocopy) a. Citizenship No : __________________________ b. Issuing Date : __________________________ c. Place of Issue : __________________________

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 Passing Institute Total Marks AGGREGATE MARKS Marks Obtained %age of marks

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

Class – XII

(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