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VISHNU

This document contains an application form submitted by Vishnu Kumar Kushwah for the Joint Admission Test for M.Sc. (JAM) 2012. It provides details of the applicant such as name, date of birth, category, contact information, as well as test paper and city preferences. Payment was made through demand draft number 365277 of Rs. 900 drawn on State Bank of India dated 11/10/2011.

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62 views2 pages

VISHNU

This document contains an application form submitted by Vishnu Kumar Kushwah for the Joint Admission Test for M.Sc. (JAM) 2012. It provides details of the applicant such as name, date of birth, category, contact information, as well as test paper and city preferences. Payment was made through demand draft number 365277 of Rs. 900 drawn on State Bank of India dated 11/10/2011.

Uploaded by

vishnukushwaha_328
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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APPLICATION NUMBER :

206025
DETAILS OF CANDIDATE

Date : 15/10/2011

Name of the Candidate (As in 10th Class Certificate) : Nationality : Indian No Person with Disablity :

VISHNU KUMAR KUSHWAH Gender : Male Scribe Required : Category : OBC (Non-creamy) Date of Birth : 03/08/1990 Relationship : Father

Name of Father/Mother/Guardian:

RAMLAKHAN KUSHWAH CHOICE OF TEST PAPER [S]

No. of Test Paper[s] Applied :

Session 1 : [CA] Computer Application CHOICE OF CITIES/TOWNS FOR THE TEST

Session 2 :

Choice of Cities/Towns for the Test

First Choice : [504] Bhopal

Second Choice : [308] Indore

DETAILS OF QUALIFYING EXAMINATION Qualifying Degree : Others Qualifying Examination Passed : 69.33 DETAILS OF DEMAND DRAFT DD No. 365277 Nationalised Bank Drawn On State Bank of India SOURCE OF INFORMATION OF JAM 2012 I found out about JAM 2012 through : Friends/Seniors/Professors DETAILS OF CONTACT ADDRESS Name :
(DO NOT STAPLE)

Yes

Year of Qualifying Exam : CGPA (out of 10) :

2011

Percentage of Aggregate Marks :

Other

Date 11/10/2011

Amount 900

VISHNU KUMAR KUSHWAH 18, ZONE-2, IMPETUS CAMPUS M P NAGAR

Address :

Paste a Front Facial High Contrast Recent Colour photograph (3 cm X 4 CM) without any signature or attestation

BHOPAL

State :

Madhya Pradesh

Pin Code : 462016 Email : Phone : [email protected] 07552768319

Mobile No : 09907525380 DECLARATION BY THE CANDIDATE: FULL SIGNATURE OF THE CANDIDATE(IN BLACK INK BALL-POINT PEN) 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 the information Brochure and I shall abide by the terms and conditions therein. In the event of suppression or distortion of any fact made in this application form, I understand that I will be denied the opportunity to appear in the JAM 2012, and if already appeared/ selected/ admitted, my admission/ degree acquired is liable to cancellation. Place : Date :
FULL SIGNATURE OF THE CANDIDATE (IN BLACK INK BALL-POINT PEN)

206025

BY REGISTERED POST/SPEED POST APPLICATION FORM


PAPER CODE EXAM CITY CA 504 308 To ORGANIZING CHAIRMAN, JAM 2012 INDIAN INSTITUTE OF TECHNOLOGY BOMBAY From
VISHNU KUMAR KUSHWAH

POWAI, MUMBAI PINCODE 400076

18, ZONE-2, IMPETUS CAMPUS M P NAGAR BHOPAL

APPLICATION NO

206025
PINCODE 462016

Madhya Pradesh

CHECK-LIST
1.Cut the above address slip along the dotted line and paste the address slip on the envelope containing your completed application form with your photo pasted on it and your two signatures. You must write your name and application number at the back side of the photograph before pasting it within the box provided in the application form. 2.You must enclose the attested copies of all relevant certificates (SC / ST / PD / Affidavit for change of name, if applicable) and the demand draft in the envelope. 3.Send the envelope by speed / registered post only. Application sent by courier will be rejected.

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