CAT PREPARATION CLASS FOR CAT 2022

Application Form
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 Please paste
your recent
photo here

1 First Name: 2 Surname:

(as you wish it to appear on the certificate)

3 Date of Birth: / / 4 Sex: Male Female

( day / month / year ) (tick as appropriate)

5 Address for Correspondence:

Tel/Mob: Email:

6 ID Proof Enclosed :

7 Nationality: 8. Mother Tongue:

9 Educational Level / Qualification/ Studying in:

10 Name of the Educational Institution / Organization you are currently at:

I certify that the information provided in this form is complete and accurate to the best of my knowledge. I understand that I must abide by
the rules and regulations laid down by Nirma University and agree to the same. Registration charges are non-refundable.

Fees of Rs. 35,000/- can be paid by Demand Draft/Local Cheque. Demand Draft / Cheque should be drawn in favor of “Centre for Continuing
Education, Nirma University” payable at Ahmedabad.

Signature: Date:

Valid id proof: Enclose a photocopy of Institute ID.

Bank Details

1 Account Name Centre For Continuing Education

 Nirma University Sarkhej Gandhinagar Highway,
2 Address
Ahemdabad-382481

3 Name of the Bank The Kalupur Com.Co.Op.Bank Ltd.

4 Name of the Branch Nirma University

Nirma University Sarkhej Gandhinagar Highway,

5 Branch Address
Ahemdabad-382481

6 Bank IFSC Code KCCB0NRM097

7 9 Digit MICR code 380126029

8 Bank Account No 09720180200