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Acknowledgement No.: ACKC11147871

Application Form for Registration to Common Proficiency Test Course

1.Name in full (As per SSC X certificates) First Name: Middle Name: Last Name: 2.Sex: 3.Date of Birth: 4.(a)Mother's Name: 4.(b)Father's Name: 5.(a)Address For Communication: Address Line 1: Address Line 2: Address Line 3: Address Line 4: City: Pin: Country: Email id: Address Line 1: Address Line 2: Address Line 3: Address Line 4: City: Pin: 6. Category 7. Nationality: 8. Medium of study: NEW DELHI 110014 Gen Indian English
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Rohit Mittal Male 11-02-1995 Sangeeta Mittal Rajesh Mittal 30, bazar lane bhogal

NEW DELHI 110014 INDIA

State Code: DELHI Phone No. with STD Code: 01124374975 Mobile No.: 9654172577

rmrmittal2@gmail.com 30, bazar lane bhogal

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

State Code: DELHI Country: INDIA

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

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

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Examination 10th 12th Degree Diploma

Board/Authority CBSE

Year 2011

Result Marks Obtained 6 Max Marks 10 Yes Yes Yes Awaited

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 6300 Declaration I hereby declare that the information furnished herein above is true to the best of my knowledge.

Total Amount Paid:

Date: Place:

27-01-2013 New Delhi

Signature of applicant

Name _______________________________________

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