APPLICATION NUMBER

3203705

PAYMENT MODE

CREDIT CARD

COURSE GROUP

15

AMOUNT

2000

COURESES/APPLIED

[MDS]

DD NUMBER

NA

TEST CENTER

Delhi,Noida

DD DATE

NA

DATE OF BIRTH

05/8/1987

CATEGORY

GENERAL

SEX

Male

NATIONALITY

India

NAME OF THE APPLICANT

Rajan

NAME OF THE PARENT/

GUARDIAN

Rajesh Kumar Mishra

ADDRESS LINE 1

c/o Rajesh Kumar Mishra

ADDRESS LINE 2

Behind old power house

ADDRESS LINE 3

jagat deo talab road

PIN

485001

STD CODE/TELEPHONE
NUMBERS

NA

CITY

satna

E-MAIL ADDRESS

savyasachi09@gmail.c om

STATE

Madhya Pradesh

MOBILE NUMBER

+917835875398

DATE OF COMPLETION OF
INTERNSHIP

07/2/2012

FOR MD/MS
APPLICANTS
ARE YOU A DIPLOMA
HOLDER?

Mishra

FOR MTECH
APPLICANTS
NO

ARE YOU A GATE SCORER? NO

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.The candidates who are appearing for GATE exam should submit the valid score card on or before the last
date of receipt of application (For MTech / MSc Tech applicants only)
4.Please send this completed application form with DD/Challan(if payment is not via Credit Card) to: Director Admissions, Manipal University, Manipal - 576104