Application Form

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Candidate Details
Name Uday Nauhbar
Date of Birth 2003-11-10 Gender M
Father's Name Vijay Kumar Current Class XI Undergoing
Mother's Name Rekha Rawat
Address 26
City Agra State Uttar Pradesh
Pincode 282007
Mobile 9411061966 Mobile2 ______________

Registration and Purchase Details

User ID OL78171208788 Order ID 1504956
Transaction Date/Time 2020-10-09 23:26:53 Payment Mode online
Online Txn. 109984447607 Amount Rs 5000

Application No. Courses Purchased Course Code Scholarship Code Fee

Nurture - Online Test Series for JEE Main
20660941 1121 N/A Rs 5000
and Advanced 2022

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 this form are true to the best of my knowledge.
If I get selected in Pre-Medical Exams or Pre-Engineering Exams or Talent/Olympiad Exams or any Competitive
exams then ALLEN Career Institute can publish and display my name and photograph and other information for
publicity (print & social media) purpose.
All disputes are subject to Kota (Rajasthan) Juridiction only.

Date: Place: ______________

Signature with date (Applicant) Signature with date (Father/Guardian)

Administrator (E-learning Division)

ALLEN Career Institute
SANKALP, CP-6 Indra Vihar Phone: +91-744-2752200 (09:00 AM to 05:00 PM)
Kota - 324005 Email: support@onlinetestseries.in
Rajasthan, India

Print Date: 10/10/2020 02:00 AM