B.

TECH APPLICATION FORM 2023 (PHASE-2)

APPLICATION NO :23012004176

Program And Campus Preference

Campus SRMIST, Main Campus Program Computer Science Specialization Computer Science
Preference 1 (Kattankulathur, Chennai) Preference 1 And Engineering Preference 1 And Engineering
Campus SRM University Delhi - Program Computer Science Specialization Data Sciences And
Preference 2 NCR,Sonepat (HR) Preference 2 And Engineering Preference 2 Aritifical Intellegence
Artificial Intelligence
Campus SRM IST Delhi NCR Program Computer Science Specialization
And Machine
Preference 3 Campus, Ghaziabad (UP) Preference 3 And Engineering Preference 3
Learning

Personal Details
Nationality Indian
Have You Studied From India? Yes
Student Aadhar No.
Full Name (As Per The Qualifying Examination
Ansh Gupta
Certificate)
Mobile No. +91-7007793675
WhatsApp Mobile Number +91-7007793675
Email ID ansh.gupta10000knp@gmail.com
Alternate Email ID
Date Of Birth 30/03/2005
Gender Male

Family Details
Parent Details :Father
Father Mother Guardian
Title Mr
Name Vikas Gupta
Mobile Number +91-6306702842
Email Address

Address Details
297 Sarkar Road Rail Bazar cantt
Address : Pin Code : 208004
Kanpur
Country Name :India State : Uttar Pradesh District : Kanpur Nagar City: Kanpur Nagar

Academic Details
Current Education Qualification Status : 12th Appearing
XII Details : X Details :
Institute Name Seth Anandram Jaipuria School Kanpur Seth Anandram Jaipuria School Kanpur
Council Of Indian School Certificate Examination Council Of Indian School Certificate Examination
Board
(CISCE/ISC) (CISCE/ICSE)
Mode of Study Regular Regular
Marking Scheme Percentage
Percentage / CGPA 93.4
Year Of Passing 2021
Hall ticket No./Registration No.
Address Of School/College 70, Cantonment Kanpur -
NAD ID/Digilocker ID -
Payment Details
Transaction ID 112772762332
Payment Date 20/01/2023
Mode Of Payment

Declaration
I Certify That The Information Submitted By Me In Support Of This Application, Is True To The Best Of My Knowledge And Belief. I Understand
That In The Event Of Any Information Being Found False Or Incorrect, My Admission Is Liable To Be Rejected / Cancelled At Any Stage Of The
Program. I Undertake To Abide By The Disciplinary Rules And Regulations Of The Institute

Applicant Name :Ansh Gupta

Parent Name :Vikas Gupta

Date :20/01/2023