Application No 120128055 Category GENERAL

Name of the Candidate DIVYANSH AGARWAL

Name of the Guardian RADHA AGARWAL
Date of Birth 02/1/2002 Gender Male
Course group 2 Test Center Agra
Nationality
Course Name BTech (Bachelor of Engineering) India

Address
H.No. 14 Kanhiya Kunj

Near St. Columba's School Mughal Road

Kamla Nagar
City Agra State Uttar Pradesh Pincode 282005
Email Id1 thedivyanshagarwal01@gmail.com Mobile No1 8273357080
Email Id2 agarwalradha20880@gmail.com Mobile No2 9458558947

Payment Details
Payment Instrument No 120128055-1573649919281
Payment Mode Debit Card Date 13/11/2019 Amount 2000

Declaration:

I understand that I can apply only once for each program/ group. In case I apply more than once, only one of my application will be
accepted and the application, entrance test fees remitted will not be refunded.

I hereby declare that all the particulars stated in this application form are true to the best of my knowledge and belief. I have read
and understood all provisions of admissions and agree to abide by them. I also affirm that I fulfil the eligibility requirements for the
course/s applied.

In the event of submission of eligibility document from the unrecognized Board/ University, fraudulent, incorrect or untrue
information or suppression or distortion of any fact, like educational qualification, marks, nationality etc. I understand that my
admission is liable for cancellation.

Signature of the Applicant

NOTE :1. Please keep a copy of the filled in application for future reference (Don’t Send the Copy).
2. Application number must be quoted in all future correspondence.
Manipal Academy of Higher Education (MAHE) | Manipal – 576 104, Karnataka State, INDIA
Tel: +91 92437 77700/11/22/33/44 | email: admissions@manipal.edu | Web: www.manipal.edu