application form
DESCRIPTION
apllication formTRANSCRIPT
-
Phone: +91-744-5162-222 (10:00 AM to 07:00 PM)Email: [email protected]
Date: ______________ Place: ______________
Signature with date (Applicant) Signature with date (Father/Guardian)
Affix latestpassport size
colorphotograph
Application Form
Candidate DetailsName sourav raiDate of Birth 1998-01-09 Gender MFather's Name AKHILESH KUMAR RAI Current Class XII PassedMother's Name SUMAN RAIAddress 16F/2A ALKA VIHAR COLONYCity ALLAHABAD State Uttar PradeshPincode 211011Mobile 7376433701 Mobile2 ______________
Registration and Purchase DetailsUser ID [email protected] Order ID 69526Transaction Date/Time 2016-01-09 20:12:14 Payment Mode onlineOnline Txn/DD No. ESM24224633156 Amount Rs 500
Note: Enclose DD with this application in case payment mode is demand draft
Application No. Courses Purchased Course Code Scholarship Code Fee
15205725 Major - Online Test Series for JEE Main2016 6111 N/A Rs 500
DeclarationI 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 then ALLENCareer Institute can publish and display my name and photograph on its website.All disputes are subject to Kota (Rajasthan) Juridiction only.
Send the complete application form along with all required enclosures to the following address :Administrator (E-learning Division)ALLEN Career InstituteSANKALP, CP-6 Indra Vihar Kota - 324005 Rajasthan, India