Admissions to 5 year BS-MS Degree Programme 2017

Declaration
To be given by the Candidate who does not have all necessary documents and is provisionally admitted

Please tick appropriate boxes

1. Application Number:
Paste your recent
2. Stream: KVPY JEE Advanced SCB
Passport size
3. Category: GE OBC-NCL SC ST KM Photograph here
4. PD: YES NO
5. Applicants Name:
6. Parents/Guardians Name :

I understand that my admission to IISER Berhampur/ Bhopal / Kolkata/ Mohali/ Pune/

Thiruvananthapuram/ Tirupati is provisional due to my non submission of the eligibility examination
certificate and / or mark sheet, satisfying the eligibility criteria laid down on the website
(www.iiseradmission.in) , due to my appearing in the examination in the year 2017, and the result for
the same examination is not yet declared.

I also declare that in the event of my failing to fulfill the eligibility criteria listed on the above website
on or before August 31, 2017, my provisional admission to any of the IISER will stand cancelled.

Signature of the Candidate

Place
Date Signature of the Parent / Guardian