APPLICATION FORM

GRADUATE PHARMACY APTITUDE TEST(GPAT)-2012 (All India Council for Technical Education)
Application No. : 108814 Application Date : 24-01-2012 Application Fee : 500.0

108814

1.Name of the Candidate : ARINDOM MITRA

(as given in the 10th Class Certificate)

2. Date of Birth : 13-09-1985 3. Name of Parent / Guardian : COL. (RETD) A. K. MITRA 4. Relationship of the Parent / Guardian to the Candidate: FATHER 5. Nationality : INDIAN 6. Gender : MALE 7. Category : GENERAL 8. Person with disablility(PD) : YES 9. State / Union Territory in which your college / institute is located: UTTAR PRADESH 10. Choice of Examination City 1 : ALLAHABAD 11. Choice of Examination City 2 : LUCKNOW 12. Year of Qualifying exam : 2012 13. Landline No. with STD code : 05322466953 14. Mobile No. : 09935612324 15. Email Address : aditya1764@gmail.com 16. Address for Correspondence : 38 B/ 22 TAGORE TOWN

ALLAHABAD - 211002 UTTAR PRADESH ( INDIA )

17. Bank Details : Application Fee SOL Id Transaction Number Payment Date : : : :

500.0 1033 00518003 24-01-2012

18. Place : 19. Date :

Undertaking :
I solemnly affirm that the information furnished in this application is true and correct in all respects. In the event of suppression or distortion of any fact made in this application I shall be liable to civil/ criminal prosecution and forego my claim to appear in GPAT-2012 examination, and if already appered / selected / admitted my admission / degree acquired is liable for cancellation. I agree to abide by the rules and regulations governing GPAT-2012 Examination, and as given in the website www.gpat.in

Signature of the candidate

BY SPEED/ REGISTERED POST

GPAT-2012 APPLICATION FORM

108814

Do not tamper with the bar code

TO, THE CO-ORDINATOR, GPAT 2012 SHRI G.H. PATEL PHARMACY BUILDING, OPP. UNIVERSITY MAIN OFFICE, DONORS' PLAZA, FATEHGUNJ VADODARA - 390 002 GUJARAT, INDIA

From : ARINDOM MITRA 38 B/ 22 TAGORE TOWN ALLAHABAD - 211002 UTTAR PRADESH ( INDIA )