Application Form

Candidate Details
Name SAPTASHWA BHATTACHARJEE
Date of Birth 2002-08-24 Gender M
Father's Name AMIT Current Class XI Undergoing
Mother's Name SUSMITA
ANANYA APARTMENT FLAT NO A2 522/1 BORAL MAIN ROAD LAHABAGAN
Address
GARIA KOLKATA 700084
City KOLKATA State West Bengal
Pincode 700084
Mobile 9775843583 Mobile2 ______________

Registration and Purchase Details

User ID mail4amit1513@gmail.com Order ID 556887
Transaction Date/Time 2019-06-26 21:53:37 Payment Mode online
Online Txn/DD No. 108613253527 Amount Rs 5000
Note: Enclose DD with this application in case payment mode is demand draft

Application No. Courses Purchased Course Code Scholarship Code Fee

Nurture - Online Test Series for JEE Main
19656408 1121 N/A Rs 5000
and Advanced 2021

Declaration
I hereby accept that no refund will be made if I join ALLEN's Online test series by paying the prescribed fee.
I hereby declare that the information provided by me in this form are true to the best of my knowledge.
If I get selected in Pre-Medical Exams or Pre-Engineering Exams or Talent/Olympiad Exams or any Competitive
exams then ALLEN Career Institute can publish and display my name and photograph.
All disputes are subject to Kota (Rajasthan) Juridiction only.

Date: 27-06-2019 Place: KOLKATA

Signature (Applicant) Signature (Father/Guardian)

Administrator (E-learning Division)

ALLEN Career Institute
SANKALP, CP-6
Indra Vihar Phone: +91-744-2752200 (09:00 AM to 08:00 PM)
Kota - 324005 Email: support@onlinetestseries.in
Rajasthan, India