| Academics Name * : |  | Course Name* : |  | 
     
     
     | Membership No * : |  |  |  | 
     
     
     | Personal Information | 
     
     
     | Student Name * : |  |  | ![]()  
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     | Father's Name * : |  |  | 
     
     
     | Mother's Name * : |  |  | 
    
    
     
     
     | Date of Birth : |  | Nationality : | Sex : | 
     
     
     | Religion * : |  | Category * : |  | 
         
          
     | Complete Address *: |  | 
     
     
     | State : |  | Dist : | Pin No * : | 
     
     
     | Contacat No (with STD) : |  | Mobile No * : |  | 
     
     
     | Educational Information | 
     
     
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     | Declaration : I acknowledge to have fully read the prospectus and certify that i have understood all the provision indicated there in I certify that i am qualified for the program as indicated in the prospectus. I understand that my admission is liable to be cancelled if i suppress or distort any information famished in my application. I understand fee once paid will not be refunded. I will maintain all the rules & regulation of this institute.' | 
     
     
            
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