GOETHE-INSTITUT / MAX MUELLER BHAVAN MUMBAI

EXAMINATION FORM

(Please fill the form in CAPITAL LETTERS: Any changes after submission will attract apenalty of Rs.1500/-
Examination Fee payable by cash or deman dratf in favour of “Max Mueller Bhavan”)

(Mr./Ms.) Surname __________________________________ Name __________________________________

Date of Birth __________________________________ Place of birth __________________________________

Address ______________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

Email id: __________________________________ Res: _________________ Cell: ___________________________________

International Examination: SD1 SD2

GZ B1 lesen hören schreiben sprechen

GZ B2 GZ C1 PWD

GZ C2-GDS lesen hören schreiben sprechen

Date of the exam: ______________________ Centre: _________________ Timing: _____________________

I am appearing for this examination for Spouse Visa Higher Studies in German

Other reason, please Specify _______________________________________________

I have seen the examination schedule and I am paying Rs.____________ Cash/Demand Draft as examination fee.

Particulars:

Cash: Please specify the serial no. of the notes:

Rs. 2000 : ________________________________________________________________________________________________

Rs. 500: _________________________________________________________________________________________________

Rs. 100: __________________________________________________________________________________________________

Demand Draft no: ________________ drawn on: __________________ date: _________________

(The candidate must carry the examination receipt and a valid photo ID proof at the time of the exam and produce the same on demand)

I hereby confirm that I have taken note of the application “Exam Guidelines” and “Terms & Conditions” for the

“Exam Administration” and agree to abide by the same.

________________________ ___ ----------------------

Signature of the student Place, Date
Declaration of consent
Surname, First Name:

On executing my signature below, I consent to the transmission and storage by Goethe-Institut / Max Mueller
Bhavan of my personal data (“data”) provided under the terms of my registration and in conjunction with the
performance of future agreements to its headquarters in Munich, Germany (“GI-HQ”) and there to combine in
its central customer database said data with any other of my personal data previously provided and stored
there, if applicable.

Furthermore, I consent to the use of my data by Goethe-Institut / Max Mueller Bhavan and GI-HQ not only for
performing the contractual agreement, but also for the purposes of market research, advertising and
marketing associated with the range of services offered by Goethe-Institut / Max Mueller Bhavan and, in
particular, for providing relevant advertisements or surveys (“Information”), e.g., about new courses offered
by Goethe-Institut / Max Mueller Bhavan to me at the contact address I have provided, either by post or – at
my special request – also by telephone, fax, email, or text message.

Data concerning examinations I have taken, may also be transmitted to GI-HQ for storage and use in the
central examination archives (for a maximum period of 10 years) for verification purposes and for issuing
replacement certificates, as required.

Goethe-Institut / Max Mueller Bhavan will not use my data for any other purpose than those specified in this
consent agreement or provide any data to a third party, unless there is a reasonable suspicion of abuse
concerning the data.

I have been informed that I may revoke my permission to use my data for market research, advertising and
marketing purposes at any time.

Place, Date, Signature

Yes, I would also like information sent to me by email/text message/telephone/fax.

Place, Date, Signature

Right of Revocation
You may exercise your right to revoke by completing the section below, either now or at some future time:

I hereby revoke my permission, effective immediately, for the use of my data for advertising and marketing
purposes.

Place, Date, Signature