APPLICATION FORM - 2013

Stream SX

sb2

Application No.

1428829
: Aniket Agrawal : 19/06/1996 : General : No : Indian : Male : ASE120301200276 ASE12030120027

Name of Candidate (as in 10th Marks Card) Date of Birth (dd/mm/yyyy) Category Person With Disability (PWD) Nationality Gender X Board Registration Number

Exam Board

Science

Maths

% of marks in Aggregate in Science subjects & Mathematics 95

X Std (% marks)

CBSE

95

95

X Std Board (if others): In the academic year 2013-14 I have joined: XII Standard in Science Subjects Centre for writing Aptitude Test Language in which would like to take your Aptitude Test Name of College/Institution Address of College/Institution : Vadodara : English : The New Tulip International School : Sterling City Bopal Ahmedabad 380058 Gujarat

Declaration by the student I declare that the information provided above are true to the best of my knowledge and belief. I understand that if it is found that I do not meet the eligibility norms at any point of time I may face disqualification from the KVPY program. 33,Suruchi Appartments , 22 Shantisadan Society Ellisbridge Paldi Ahmedabad Gujarat 380006 Candidate Signature:

07926422287 mlal1993@yahoo.co.in CERTIFIED BY THE COLLEGE/INSTITUTION Mr. Aniket Agrawal is a bonafide student of The New Tulip International School and his date of joining XII Standard in Science Subjects is on: and all the information furnished by the applicant is correct.

Date: Place:

Signature of the Head of the Institution Name: Institution Seal:

Your application for "Stream SX" has now been incorporated into our system and you have been assigned the Application number

1428829.

However, your application is not complete until you do the following:

1. 2. 3. 4. Take a print out of this Application Form and make sure that it is complete with a number. Please also obtain your School / College Principals signature and seal in the appropriate place. Do not make any changes / alterations to this page. Application Fee: An application fee of Rs. 500/- may be remitted to any core banking branch of STATE BANK OF INDIA, to the credit of Kishore Vaigyanik Protsahan Yojana (KVPY) A/c. No. 10270577392 Download the challan/pay-in slip in .pdf format (http://www.kvpy.org.in/kvpy-1314/downloads/pay-in-slip.pdf) or Download the challan/pay-in slip in .doc format (http://www.kvpy.org.in/kvpy-1314/downloads/pay-in-slip.doc) The application fee is exempted for the following category of students: 1. Students belonging to SC/ST. 2. Physically and Visually challenged students (Person With Disability - PWD) 5. The completed application form along with the following documents super scribing on the envelop the stream applied for, should reach the KVPY office on or before 2/09/13: o Caste certificate issued by the competent authority in the prescribed proforma in the case of SC/ST students. o Medical certificate from the prescribed authority in case of physically and visually challenged students certifying the percentage of disability. o Copy of the marks statement of the qualifying examinations(s). o Original Pay-In-Slip of the Application fee of Rs. 500/- (if applicable). Send all the above documents through Speed Post or Registered Post, to The Convener, KVPY Indian Institute of Science Bangalore 560 012 KVPY will not be responsible for postal delays in receiving the completed application form. You may check to see that your application is complete and all documents received at the KVPY office by visiting to http://www.kvpy.org.in/ after two weeks of the posting of your application.

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Issue of hall ticket through KVPY website (for online applicants only): Website URL: http://www.kvpy.org.in/ Login ID Application number Password Date of Birth

Application No.

1428829