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Application Number:: Programs Course Groups - (Courses)
Application Number:: Programs Course Groups - (Courses)
Application Number:: Programs Course Groups - (Courses)
2030749
PROGRAMS
Course Groups - [Courses]
Test Centers
Delhi,Gurgaon
BASIC INFORMATION
First Name
Pritam
Email ID
bijayaketan.panigrah
i@gmail.com
Last name
Panigrahi
Mobile Number
9582782220
Parent's Name
Phone Number
9818275326
Gender
Male
Address
Warden house
Aravali hostel
IIT delhi , Hauz khas
Nationality
Indian
Student Photo
Student Signature
Pg 1 of 3
EDUCATION QUALIFICATION
University Name
12th
Board/University
cbse
Year of Passing
2015
ONLINE(CCAvenue)
Payment Amount
1600
PAYMENT DETAILS
Payment Type
OTHER INFORMATION
Date of Completion of
Internship
Exam Name
Exam Score
Registration No:
Completion Year
I confirm that I fulfil the eligibility criteria for the course I am applying for.
I understand that no refund will be made on the application fee if I am not eligible for the programmes I am applying for.
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DECLARATIONS
I hereby declare that all the particulars stated in this application form are true to the best of
my knowledge and belief. I have read and understood all provisions of admissions and agree
to abide by them. I also affirm that I fulfil the eligibility requirements for the course/s applied.
In the event of submission of fraudulent, incorrect or untrue information or suppression or
distortion of any fact, like educational qualification, marks, nationality etc. I understand that my
admission/degree is liable for cancellation. I further understand that my admission is purely
provisional subject to the verification of the eligibility conditions. NOTE: 1. Please keep a copy
of the filled in application for future reference. 2. Application number must be quoted in all future
correspondence. 3. Please mail the printed copy of the completed application form along with
the DD/Challan (if payment is not via Credit / Debit Card) to: The Director, Admissions, Manipal
University, Manipal - 576104
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