Form Name BTech - (General)

Application Number 122129030

Applicant Details
Name HAMMAD SHAIKH
Gender MALE Date of Birth 11/05/2004 Nationality INDIA
Mobile Number +91-9054044950 Email ID MR.COOKIE7979@GMAIL.COM

Category Details
Category GENERAL Sub Category GENERAL

Program Details
Program Level UNDER GRADUATION - UG Stream ENGINEERING
Course BTECH
Tentative Test Center Location BARODA

Parent Or Guardian Details For Communication

Full Name ASIF SHAIKH Email ID BODY_POOL2000@YAHOO.CO.IN
Earning member of your
Mobile Number +91-9825245300 FATHER ONLY
family

Address Details
F-6-BISMILLAH MANZIL, NO-2-BHAGYODAY SOCIETY, OPPOSITE RAILWAY STATION, ANKLESHWAR CITY, GUJARAT
City ANKLESHWAR State GUJARAT Country INDIA Pincode 393001

Payment Details
Transaction No 4101249 Payment Mode Online
Date 24/02/2022 Amount in Rs. 2000

Declaration
• I hereby confirm that the above-mentioned details are correct.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 program(s) applied. I understand that I can
only apply once for each group. In case I apply more than once, only one of my application will be accepted and the
application and entrance test fees remitted will not be refunded.

• If it is found at a later stage, during active verification, that I have given false or incorrect or untrue information w.r.t
educational qualification, marks, nationality etc., or submitted an eligibility document from the unrecognized board or
university, my admission or degree will be cancelled without any notice, with forfeiture of all the fee paid.

• Jurisdiction for dispute if any shall be at Udupi Court, Karnataka, India only.