Family name, given name: Puthervessl Poulose, Lis Ena lio. cse@gmailcom Date of bith: 26.05.1989 Gender: divers InGermany: No German language level Nationality: India Desie for German course: Technische Universitat Clausthal Internationales Zentrum Clausthal Graupenstrafe 11 38678 Clausthal-Zellerfeld Germany German course participant Date: 06/02/2021. Application to study starting in winter term 2021/22 To whom it may concern hereby apply for a place on the following program: Applicant no. Degree program Semester 120627 Master's degree in Computer science 1 semester enclose the required documentation with this application: + A certified copy, plus a transiation*, of my university entrance qualification “Documents in English or French do not need to be translated + Evidence of any previous university studies outside Germany (e.g. transcript of records, i applicable) ‘A cutrent and complete resume Certtication of my English language skils that complies with the specific prerequisites of my chosen degree pro- gram Master's degree in Computer science + A receipt showing that I have paid the administration fee of 75,00 euros or 55,00 euros for applicants trom China or Vietnam with an APS certtcate into the folowing account: Bank: NORD LB; IBAN: DES 2505 0000 0152 0002 38; BIC: NOLADE2H, citing the reterence "Kostenstelle 3002 0350 Lijo Puthenveetil Poulose, 26.05.1989" or evidence that | am exempt trom paying the administration tee A cetttied copy, plus a translation, of my university degree certiticate including my transcript of records or a current and detailed summary of my grades: hereby affirm that all the information | have provided in this application process and that which | have sub- mitted online is complete and correct. | am aware that providing incorrect information, whether intentionally or through negligence, is an offense and would result in my exclusion from the application process or, if dis- covered after had been admitted, in the revocation of my university admission | consent to my personal data being used for the purposes of the applications process. | am aware that, if my application is unsuccessful, the documents | have provided will be destroyed. | furthermore affirm in lieu of an oath that the information about periods of study and degrees gained is cor- rect Yours faithfully, (ifthe applicants @ miner, his application must be signed by ther legal guacian) 03.06.2021 dP toe Date, signature of applicant Date, signature of egal guardian Page 1 of 1