General Application Form

Application No: IPEC/2021/3198

Personal Details
Select Course Preference
Course Applied For UNDERGRADUATE Level IST YEAR Specialization 1 CSE
Specialization 2 Specialization 3 Specialization 4
Specialization 5 Specialization 6
Personal Details
Title MR. First Name VANSH Middle Name
Last Name KANSAL Gender MALE Email ID VANSHKANSAL2004@GMAIL.COM
Date of Birth 28/01/2004 Place of Birth DELHI Mobile Number +91-8383944245
Phone Number 9313590035 Religion HINDUISM Caste Category GENERAL
Aadhar Card
Marital Status UNMARRIED 356309920476 Blood Group B+
Number
EWS Certificate (if
NO Domicile of UP
applicable)
Father's Details
ARUN KUMAR Father's Mobile
Father's Salutation MR. Father's Name +91-9313590035
KANSAL Number
Father's EMPLOYED –PRIVATE Father Annual
Father's Email ID ARUNKANSAL1978@GMAIL.COM 4-5 LAKHS
Occupation SECTOR Income
51/26,G.F, NEW MARKET ,KATRA
Father's Office MEDGRAN,ISHWAR Father's Aadhar
Father's Aadhar YES 969152545507
Address BHAWAN,KHARI Number
BAOLI,DELHI-110006
Mother's Details
Mother's Mother's Mobile
MRS. Mother's Name MEENU KANSAL +91-9599347227
Salutation Number
Mother's Mother Annual
Mother's Email ID MEENUKANSAL03@GMAIL.COM HOMEMAKER
Occupation Income
Mother's Mother's Aadhar
Mother's Aadhar YES 902513641810
Occupation Number
Address for Communication
Country INDIA State DELHI District SHAHDARA
Correspondence 6/194,DOONGER Correspondence FARSH BAZAR , TRUNK STREET
City SHAHDARA
Address Line 1 MOHALLA Address Line 2 ,SHAHDRA
Is Permanent
Address same as
Pincode 110032 YES
Address for
Communication?
Permanent Address
Country INDIA State DELHI District SHAHDARA
Permanent 6/194,DOONGER Permanent FARSH BAZAR , TRUNK STREET
City SHAHDARA
Address Line 1 MOHALLA Address Line 2 ,SHAHDRA
Pincode 110032

Educational Details
Academic Details
10th Details

Passed from UP /
Institute Name Board Roll Number Year of Passing Aggregate Percentage
Outside State
CENTRAL BOARD OF SECONDARY
10th PUNEET PUBLIC SCHOOL 8162082 2019 OTHER| 76.3
EDUCATION (CBSE)

After 10th
12TH
Qualification
12th Details

Passed From
Year of PCM Aggregate
Institute Name Board Roll Number Result Status UP/ Outside
Passing Percentage Percentage
State
 CENTRAL BOARD OF
BHAI PARMANAND
12th SECONDARY 14606331 DECLARED 2021 OTHER| 79.33 81
VIDYA MANDIR
EDUCATION (CBSE)

12th Marks Details

Maximum Marks
Maximum Marks (Theory) Obtained Marks (Theory) Obtained Marks(Practical)
(Practical)
Physics
Computer Science
Biology
Engineering Graphics
Chemistry
Electronics
Informatics Practices
Business Studies
Mathematics
Information Technology
Technical Vocational Subject
Entrepreneurships

Diploma Details

Passed from UP/

Institute Name Board / University Roll Number Result Status Year of Passing Aggregate Percentage
Outside State
Diploma

Graduation Details

Institute Name University Year of Passing Result Status Passed fron UP / Outside State Aggregrate Percentage
Graduation

Post Graduation Details

Passed From Up Aggregrate

Institute Name University Degree/ Course Year of passing Result Status
/Potside State Percentage
Post Graduation

Whether Appeared for UPCET Registration

UPCET 2021 no/Roll No
Whether Appeared in
UPCET Rank JEE Main Roll No
JEE-Main 2021
Whether Appeared in
JEE Main Rank GATE Roll No
GATE 2020
Whether Appeared in
Gate Rank Any Other Entrance Roll Number
Examination
Rank State

Family Backgound (Candidate to give small write-up in his/her own hand writing about the family)

Upload Your Academic and Other Documents

KINDLY UPLOAD CLEAR PHOTOGRAPH AND SELF ATTESTED DOCUMENT.

Upload Your Recent Upload Mother's

Upload Father's Passport
Passport Size Photograph YES Passport Size NO
Size Photograph :
: Photograph :

Upload Scanned Copy of Upload Scanned Copy of Upload Your 10th

YES YES
Your Signature : Your Aadhar Card : Marksheet :
Upload Your 12th Upload Your Diploma Upload Your Entrace
YES NO NO
Marksheet : Marksheet : Exam Certificate :

Upload Your Graduation Upload Your Post- Upload your Domicile of

NO NO NO
Marksheet : Graduation Marksheet : UP Certificate :

Upload your EWS

NO
Certificate :

Declaration
Declaration
I HEREBY DECLARE THAT THE INFORMATION FILLED ABOVE IS CORRECT AND GENUINE, IF ANY INFORMATION FILLED BY ME FOUND INCORRECT, FALSE OR MISLEADING THEN INSTITUTION CAN
CANCEL MY REGISTRATION AND ADMISSION AT ANY POINT OF TIME .

ARUN KUMAR
Applicant Name VANSH KANSAL Parent Name Date 19/11/2021
KANSAL