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CPT MAIN

1/27/13 CPT MAIN Acknowledgement No.: ACKC11147871 Application Form for Registration to Common Proficiency Test Course

Acknowledgement No.: ACKC11147871

Application Form for Registration to Common Proficiency Test Course

1.Name in full (As per SSC X certificates)

First Name:

Rohit

Middle Name:

 

Last Name:

Mittal

2.Sex:

Male

3.Date of Birth:

11-02-1995

4.(a)Mother's Name:

Sangeeta Mittal

 

4.(b)Father's Name:

Rajesh Mittal

5.(a)Address For Communication:

Address Line 1:

30, bazar lane bhogal

 

Address Line 2:

 

Address Line 3:

 

Address Line 4:

 

City:

NEW DELHI

State Code: DELHI

Pin:

110014

Phone No. with STD Code: 01124374975

Country:

INDIA

Email id:

rmrmittal2@gmail.com

Mobile No.: 9654172577

5.(b)Permanent Address Same As Communication Address given in 5(a) above:

Yes

Address Line 1:

30, bazar lane bhogal

 

Address Line 2:

 

Address Line 3:

 

Address Line 4:

 

City:

NEW DELHI

State Code: DELHI

Pin:

110014

Country: INDIA

Please fill the circle as applicable: (Enclose proof thereof)

6. Category

Gen

7. Nationality:

Indian

8. Medium of study:

English

9.Details of Educational Qualifications: Starting from 10th standard

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CPT MAIN

Examination

Board/Authority

Year

 

Result

Marks Obtained

Max Marks

Awaited

10th

CBSE

2011

6

10

 

12th

       

Yes

Degree

       

Yes

Diploma

       

Yes

10. Annual income of Parents: INR 400000

11. In case an existing student of Professional Education (Course-I/II)

wants to switch over to CPT, please provide your Unique Registration

No.(i.e.,WRO/SRO/NRO

)

12.

India National residing in India Rs.6100/-

13.

No Subscription for Student's Journal No Subscription for Member's Journal

Total Amount Paid:

6300

Declaration

I hereby declare that the information furnished herein above is true to the best of my knowledge.

Name

Signature of applicant

Date:

27-01-2013

Place:

New Delhi

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CPT MAIN

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