17/02/2017

ApplicationforPET

REGISTRATIONNO: BHU01076716703 PAYMENTID: BHUP510767160731w

CourseName: (703)M.A.inIntegratedRuralDevelopmentand
: Management

CandidateName: ASHUTOSH
:
Father'sName: SHIVSHANKAR
:
Mother'sName: SAVITRIDEVI
:
Father's/Mother'sMobile 8299181343
Number:
/:
DateofBirth: 30.December.1992
`:

Sex/ : MALE Category/: General

BloodGroup: NOTKNOWN Employee'sWard: NO

:

:
PhysicallyChallenged: NO SportsSeat: NO
: :

Nationality/: Indian Doyoubelongto"BHUStudent NO

Category"?:
Religion/: HINDU ..

AddressForCorrespondence PermanentAddress
Name: ASHUTOSH Guardian'sName(If SHIVSHANKAR
Applicable)
Address(): VILLNARTHUA
Address(): VILLNARTHUA
POSTAURAI
POSTAURAI

District(): BHADOHI
District(): BHADOHI
State(): UttarPradesh
State(): UttarPradesh

Pin( ): 221301 Pin( ): 221301

Ph.No.withSTDCode Ph.No.withSTDCode
FaxNo.
MobileNo.() 9452666771
MobileNo.() 9452666771
Email pankajmaurya192@gmail.com

DistanceofyourResidencefrom 2099 AnnualIncomeofyour Lessthan2,00,000

BHU. Parents/GuardiansinRs.

TestCenterPreference
Preference01 VARANASI Preference04 GORAKHPUR
Preference02 RGSCMIRZAPUR Preference05 DELHI
Preference03 ALLAHABAD

SignatureUploadedby
thecandidate

ItisherebyconfirmedthatIhavecarefullyreadtheconcernedInformationBulletinavailableontheBHU'sEntranceTestPortal(www.bhuonline.in)beforefillinguptheApplicationForm.
IherebysolemnlyaffirmthattheinformationfurnishedinthisOnlineApplicationFormistrueandcorrecttothebestofmylnowledgeandbeliefandnomaterialinformationhasbeen
concealedorsuppressed.Ifanyinformationisfoundtobefalse,incorrectormisleading,theBanarasHinduUniversityshallhavetheauthoritytocancelmycandidature/admission
withoutanyfurtherenquiryornotice.
Iundertakethat,ifadmitted,IshallabidebytheUGCRegulationsonCurbingtheMenaceofRagging,2009,OrdinancesgoverningthedisciplineofstudentsofbanarasHinduUniversity
andsuchotherRules,OrdinancesandRegulationsthatmaybeframedbytheBanarasHinduUniversity/UGCfromtimetotime.
IfurtherundertakethatthepreferencefortheTestcenter,Courses,DomicileandthecategoriestowhichIbelongasindicatedbymeintheonlineapplicationformshallbeirrevocable.

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