rae y g NIFT Adéssion 2018 NIFT Admission: 2019-20 Application Form * application No. * Programme applied for Test Centre Details * Date of Wrkten Test * Test Centre City Name Personal Particulars * Name * Mother's Name * Date of Birth 303475 BDES-DESIGN lam oY 20! january 2019 (Sunday) — vatna SUDHIR SINGH fashmira dev + rather's Name subash chandra singh os-pec1997 = category Bcion creamy) Note: The application is based on your self declaration as belonging to the category applied for and the requisite certification for the same. If, at any later date, its found that any or alll of the declarations made by Gandidature would automatically be cancelled leading further to forfeiture of fee. * Gender Male * Nationality INDIAN * State Domicle(State in which candidate has completed his /her class 12th Qualifying Examination): Bihar you in the application form is/are false/untrue/suppressed/ due to error(s) of omission/fraudulence, etc, your «Ate you person with sisablity (Pwo)? * Address for Communication EmailID Contact No. Qualifying Examination * Qualification: * Transaction Reference No «Receipt No/ PG RefNo, No vill-daraull p.o.-daraull p s-bhabua distriet-kaimur bhabua kaimur Bihar-821101 sud4hirL8@gmail.com - * Mobile No. 7258068329 + Status of 1042/Equivalent p, <5, Examination Passed ‘Mode of Payment: --> Credit/Debit Card 1095753, * Payment Date 12/28/2018 7:25:25 PM 201836202713919/ * Amount Szega1s26 ‘Amount F 2000 | hereby agree to the NIFT 2019 Admission guidelines and affirm that the statement made and information fumishee by me in the Online Application Form is true, complete and covrect to the best of my knowledge and belief In the event of any information being found false o incorrect or eligibility being detected before or after the examination, my canaidature wll be rejected and action can be taken against me by NIFT. 1 Rave read he conditions of eigiilty regarding educational qualifications, ete. prescribed for NIFT admissions. You are NOT required to send Application Form/any documents /receipt to NIFT. Place Date Sad Signature of Applicant (Application submitted on Friday, December 28, 2018 19:27) (Please Print the form for further reference)