Application No 120141041 Category GENERAL

Name of the Candidate TRIPTI SINGH

Name of the Guardian BHANU PRATAP SINGH
Date of Birth 22/6/2002 Gender Female
Course group 2 Test Center Ahmedabad
Nationality
Course Name BTech India

Address
Flat No-607 Aarcon Abhay Apartment

Behind Linde Office, Ratri Bazar Karelibaugh

Vadodara- 390018
City Vadodara State Gujarat Pincode 390018
Email Id1 bp.singh@larsentoubro.com Mobile No1 7573003916
Email Id2 bp.singh@larsentoubro.com Mobile No2 7573003916

Payment Details
Payment Instrument No 120141041-1575994205462
Payment Mode Credit Card Date 10/12/2019 Amount 2050

Declaration:

I understand that I can apply only once for each program/ group. In case I apply more than once, only one of my application will be
accepted and the application, entrance test fees remitted will not be refunded.

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 eligibility document from the unrecognized Board/ University, fraudulent, incorrect or untrue
information or suppression or distortion of any fact, like educational qualification, marks, nationality etc. I understand that my
admission is liable for cancellation.

Signature of the Applicant

NOTE :1. Please keep a copy of the filled in application for future reference (Don’t Send the Copy).
2. Application number must be quoted in all future correspondence.
Manipal Academy of Higher Education (MAHE) | Manipal – 576 104, Karnataka State, INDIA
Tel: +91 92437 77700/11/22/33/44 | email: admissions@manipal.edu | Web: www.manipal.edu