Conducted by

&
On Sunday,7th August 2022
at Chennai
APPLICATION FORM FOR TEST LEVEL 4 Q
(5Q/ 4Q /3Q / 2Q)
1 Name (fill in capital letters): SUBHAM PADHI
2 Gender Male Female 3. Date of Birth YEAR MONTH Date
Please tick (attach ID Proof )
🗸 2 0 0 0 0 3 3 1
4 Full Address with JN3-158, JYOTI NAGAR 3RD LANE, Affix your photo here &
sent the same as jpeg image
postal code: BERHAMPUR-760001, GANJAM, ODISHA. as per below sample

5 Phone number: 7809039523

6 Email I. D: SUBHAM.PADHI.DUDE@GMAIL.COM

7 Name of Institution studied ABK – AOTS DOSOKAI TAMILNADU CENTER

I, by submitting this form, understand and agree to all the conditions and contents of the
application form

Signature: Date: 30/06/2022

 Fill application form in bold/ capital letter Last Date for submission
 On the day of the test, you should bring your own writing utensils (black medium soft HB Friday,
pencils and eraser) and photo identification in addition to this test voucher.
8th July 2022
 NO CELLPHONE at any time at test venue – which includes test rooms, corridors, toilets,
water points etc till you leave the test building.
 Anyone found with a cell phone in his/ her hand irrespective of whether switch on or off or in
Completed Applications to
vibration mode will be sent out immediately and debarred from taking the test further and be sent to
what was written will be invalidated. natchennaiind@gmail.com
 The Exam Fee is Non – Refundable, However you can change your exam date / Test Level one
week before 7th August 2022.
 All Examinees are requested to submit hard copy of the VACCINATION CERTIFICATE
of two doses against COVID. Examinees who do not have vaccination certificate or EXAMINATION FEE:
having only one dose vaccinated they should at least submit hard copy of the COVID
NEGATIVE CERTIFICATE from the authorized hospital/ lab obtained within LAST Rs. 2360/-
THREE DAYS before 7th August 2022 for their own safety & other examinees (including applicable taxes)
safety.The Vaccination Certificate / COVID Negative Certificate has to be submitted per level per examinee
to the Proctor in your Test Room on 7th August 2022.
 Digital Submission of photo ID Proof or Two doses vaccination certificate or RTPCR
certificate will not be accepted.
 Examinees coming to the test centre without the above will be stopped at the
entrance itself and sent back.
 Please read the attached instructions before filling up the application form.
 FOR OFFICE USE
CHECK LIST
Receipt No Level Mentioned
Dated Name written
Amount ID Proof Enclosed
Payment Mode Photo Enclosed
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