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THE INSTITUTE OF CHARTERED ACCOUNTANTS OF INDIA - COMMON PROFICIENCY TEST - JUNE, 2015

Name of Candidate : SHIVAM TRIPATHI

Gender : MALE

CPT Reg. Date : 01/01/2015 Revalidation Date : 06/01/2015 Date Of Birth : 05/05/1997

E Mail : tripathis51997@gmail.com

Control No:

264841

Registration No:CRO0551844

Center Selection

Mobile No : 8791674725 Landline No : -

Region : NORTHERN REGION

Father's Name : VIJAY KUMAR TRIPATHI

Centre :DELHI / NEW DELHI - V

Question Paper Booklet Language : ENGLISH

PIN :2574 Centre Code: 510

Address S/O SHRI VIJAY KUMAR TRIPATHI

CHAMBER NO 51 1ST FOOR,

Details of Latest Previous appearances in CPT :

BLOCK NO 1 OPP BAR BHAWAN COURT COMPOUND

MM : YYYY : Roll No.:

DEHRADUN - 248001
UTTARAKHAND , INDIA

ACADEMIC DETAILS OF QUALIFYING EXAMINATION (I.E., 12TH CLASS EXAMINATION) : ALREADY APPEARED

Year : 2015

Roll No : 5809164

% of Marks secured in 12th class Examination :

Board of qualifying examination (i.e., 12th Class examination or equivalent) : CBSE

Payment Details

Transaction Date:

20/04/2015

Amount: 500 INR

Bank Transaction No : EFC_CRO0551844_1140082669

DECLARATION BY THE STUDENT

I SHIVAM TRIPATHI Son/Daughter of VIJAY KUMAR TRIPATHI hereby declare that I have not already passed CPT examination in any earlier attempt and request for permission to
present myself at the Common Proficiency Test conducted by the Institute of Chartered Accountants of India. I hereby declare that the particulars stated in this application form are true
to the best of my knowledge and belief. I have read the Guidance Notes for candidates and satisfied myself that I am eligible to appear in ensuing CPT to be held in June, 2015 and I
shall abide by the terms and conditions contained therein. I understand that my admission to CPT and result thereof shall be provisional and subject to verification of my fulfilling the
eligibility requirements in terms of Regulation 25D (as explained below) of the CA Regulations, 1988 and decision of the Council of ICAI. In the event of suppression or distortion of any
fact made in this application form, I understand that I shall be denied the opportunity to appear in CPT and if already admitted / appeared, my admission / result acquired shall be
liable for outright cancellation. I also understand that the decision of the Institute in this regard shall be final and binding upon me and I shall abide by the same.
Date:

_____________

Sign of Candidate:

______________________________

Sign of Parent / Guardian:

______________________________

Candidate's photograph

Candidate's photograph

Paste firmly with glue or

Paste firmly with glue or

adhessive like fevicol

(Do not staple) recent color
photograph of size 3.5 X
4.5 cms

adhessive like fevicol

Signature of the Candidate

(Do not staple) recent color

(Sign within the box with blue/black pen

photograph of size 3.5 X

only in the same style as signed in the

4.5 cms

CPT course Registration Form)

ATTESTED PHOTO OF CANDIDATE

NON ATTESTED PHOTO OF CANDIDATE

Dated : 18/04/2015

I do hereby certify that the photographs affixed above are that of MR./MS SHIVAM TRIPATHI Son/Daughter of VIJAY KUMAR TRIPATHI, who has signed in my presence. I have
verified and satisfied that the candidate named above is registered for CPT course with the Board of Studies of the Institute on or before 1st April, 2015 and has already
passed/already appeared / will be appearing in 12th class examination in April / May, 2015 and is eligible as per Regulation 25 D(as explained below). The particulars as furnished
have been verified by me and found correct with reference to the documents produced before me by the candidate.

Name and membership No.of the Member of ICAI /Head of

Date:
Place:

the Educational Institution /Gazzetted Officer with Seal

Signature of Member of ICAI/Head of Educational Institution /Gazzetted Officer

Tel No._________________________

Important: Please do not fold this document while posting

Explanation of Regulation 25 D:
1. The candidate should be registered for CPT course with BOS of ICAI on or before 1st April, 2015 and if registered on or before 1st April, 2012, he should have already
applied for revalidation of registration in terms of Board of Studies Announcement No. BOS/Announcement/227/13 dated 22nd January,2013 hosted on www.icai.org.
2. The candidate who has passed 12th class or equivalent examination or appeared in 12th class or equivalent examination or will be appearing in 12th class or equivalent
examination in April / May, 2015 will be eligible to appear in CPT exam to be held in June, 2015.