Declaration Form

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Candidate Details
Application Form No. 17780010
Name Ella Bhattacharya
Date of Birth 1992-10-29 Gender F
Father's Name Sudev S Engg. Stream ECE
Mother's Name Dipasri B
College Jadavpur University
College City Kolkata
Mobile1 9836108181 Mobile2 033-23217793

Registration and Purchase Details

User ID shoppersstop777goodies@gmail.com Order ID 10303
Transaction
2017-04-09 19:59:46 Payment Mode online
Date/Time
Online Txn/DD No. IUPG5276406282 Amount Rs 370
Note: Enclose DD with this declaration form in case payment mode is demand draft

Courses Purchased Course Code Scholarship Code Fee

Combo Online Test Series for GATE (ECE) 2018 7099 GATEPT80 Rs 1900

Declaration
I hereby accept that no refund will be made if I join ALLEN's Online test series by paying the prescribed fee.
I hereby declare that the information provided by me in the declaration form are true and correct to the best of
my knowledge.
I hereby agree that I will attach the photocopy of documents in support of Scholarship (if any).
ALLEN Career Institute can publish my achievements through GATE 2018 and display my details on website.
All disputes are subject to Kota (Rajasthan) Juridiction only.

Date: ______________
Signature (Applicant) Place: ______________

Send the complete declaration form along with all required enclosures to the following address :
Administrator (E-learning Division)
ALLEN Career Institute
SANKALP, CP-6
Indra Vihar Kota - 324005 Phone : +91-744-5162-222 (10:00 AM to 08:00 PM)
Rajasthan, India Email : gatesupport@onlinetestseries.in