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Course: MBA AND PGDM | Course: MBA AND PGDM | Course:MBA AND PGDM

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Reg. No.          115153 Reg. No.          115153 Reg. No.          115153
Bank Copy
| RMAT Office Copy  | Candidate Copy 
INSTITUTE ID - RMT11  | To be attached with Confirmarion Page  |
Date:     -      -  2011
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Date:     -      -  2011
Punjab National Bank
| | Date:     -      -  2011

| Punjab National Bank |

RMAT - 2011
| RMAT - 2011 | Punjab National Bank
| | RMAT - 2011
Candidate's VISHAL KUMAR
Name : BANSAL | Candidate's VISHAL KUMAR |
Father's SURESH KUMAR Candidate's VISHAL KUMAR
Name : AGARWAL
| Name : BANSAL | Name : BANSAL
Father's SURESH KUMAR
Mobile No : 9166346675 | Name : AGARWAL | Father's SURESH KUMAR
Name : AGARWAL
| Mobile No : 9166346675 | Mobile No : 9166346675
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Application Fee :  1000 | |
Bank Charges:  10 | Application Fee :  1000 | Application Fee :  1000
Total Fee:  1010 | Bank Charges:  10 | Bank Charges:  10
Total Fee:  1010 Total Fee:  1010
Denomination Rs | |
1000 x | Denomination Rs | Denomination Rs
500 x | 1000 x | 1000 x
100 x | 500 x | 500 x
50 x | 100 x | 100 x
20 x
| 50 x | 50 x
| 20 x |
10 x 20 x
| 10 x
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5x 10 x
| 5x
|
| | 5x
(Rupees   One Thousand Ten
Only) | (Rupees   One Thousand Ten
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(Rupees   One Thousand Ten
| Only) | Only)
TXN NO. :  | |
| TXN NO. :  | TXN NO. : 
Branch Name and Code: 
| Branch Name and Code: 
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Branch Name and Code: 
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Rubber Stamp of Banker | |
Rubber Stamp of Banker
| | Rubber Stamp of Banker
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Signature of the Candidate 
Signature of the Candidate 
Non refundable Signature of the Candidate 
Non refundable
Non refundable
Bank Spoc :9828365283
 
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RMAT - 2011 Form No. 115153

   1000
Application Form (Confirmation Page) Exam. Fee
1. Choice of Examination Centre and Course
Course :MBA AND PGDM
                              I.  105 - JAIPUR  
                            II. 107 - JODHPUR
2. Name of Candidate: VISHAL KUMAR BANSAL
3. Father's Name : SURESH KUMAR AGARWAL
4. Mother's Name: MADHU BANSAL
2B-22 RAJASTHAN HOUSING
5. Address:
BOARD,COLONY  
    SIROHI-307001

6. District: SIROHI  
7 State: RAJASTHAN  
8. Mobile No.: 9166346675 9. Phone No.:
10. Date of Birth: 26-01-1991 11. Sex: MALE
12. E-mail: hotiimian@gmail.com    
13. Category: GEN 14. Sub-Category:   NONE
15. State of Bonafied Rajasthan 16. Domicile Category : A
Residence  :
17. Qualifying Exam :      
Max. Marks
Detail Subject/Stream Board/University Year %
Marks Obt.
Secondary   RBSE 2006 600 400 66.67
Sr. Sec. SCIENCE RBSE 2008 650 365 56.15
      Apearing for UG Final year exam YES        
U.G. BBA RAJASTHAN UNIVERSITY 2011

Declaration
I VISHAL KUMAR BANSAL declare that I have read the rules and the eligibility criteria for RMAT-2011 given in its information Brochure. I
further declare that the information given by me in this application is true and completed in all respects to the best of my knowledge and
belief. I understand that the suppression of factor giving false information may lead to cancellation of this application. I undertake that if I am
found to have concealed/ distorted any material and information or ineligibility detected an any time before or after admission, my admission
shall be liable to be summarily cancelled without any further notice. I know fully well, that I can’t join any other course so long as I am MBA
AND PGDM student and if it is found that I have joined any other course simultaneously, my admission to MBA AND PGDM shall stand
cancelled.

Place :    
Full Signature of Applicant
Date :   (in the box)
CHECK LIST
(Note : Incomplete forms are liable to be REJECTED without notice)
(Tick mark the relevant entries)
1. Completed all entries in the On Line Application Form  
2. Paste Your Passport Size photograph if you have not uploaded it online.  
3. Attached copy of proof of Domicile of Rajasthan.  
4. Attached copy of proof of Secondary Certificate(10th).  
5. Attached copy of proof of Senior Secondary (10+2) Examination.  
6. Attached copy of proof of Graduation OR appearing in final year of graduation(if Appearing in 2011)  
7. Attached copy of proof of Category (SC/ST/OBC/SBC/PH/EX-S/KM).  
8. Signed the confirmation page.  
9. Spare photograph (Form No. & Name metioned backside) stapled with this form.  
POSTAL ADDRESS :COORDINATOR RMAT- 2011, M. L. V. TEXTILE & ENGINEERING COLLEGE, PUR ROAD, BHILWARA - 311001(RAJ.)