Note: Agent name and City has to be filled in.

CHETANYA CAREER CONSULTANTS

Admission Questionnaire Agent name ________________________________________City___________________
KURUKSHETRA
Date:
Name: __________________________________________________________ Age: _______ _________Date of Birth _______/ _______/ _______

Course Applied for: ________________________________________________________________________________________________________

University: __________________________________________________________________ My mobile no: ___________________________________

Email Id_________________________________________________________________________________________________________________________

My aggregate marks in Class 10 _____________% Year __________________ In Class 12 ______________%Year_________________

Bachelor % age ________________% Course _______________________________________________________Year completed ________________

University Name______________________________________________________________Total fails/reappears/backlog______________________

Gap in education: tick □1 year □2 years □3 years+
Tick the following:√ Tick the following:√
1. I am a female applicant Yes No
2. I am married If answer is no go to Q5, If Yes then tick the highest qualification of your husband/ wife Yes No
My spouse Qualification: tick □12th □Diploma □BA □B.Sc □BTech □BCom □MBA □MA □MCom □MTech
Other ________________________________________ Date of Marriage_________________________
3. My spouse is : □self employed □Business □Govt □ Pvt Service □Farmer □Dairy □Unemployed Yes No
Spouse ITR available : tick □Rs 2 lacs □3 lacs □3 lacs+ per yr
4. I have a children: tick □1 □2 □3. Number of children over 6 years old : □1 □2 □3 Yes No
5. I am working. If yes, I have ITR available: <2 lacs, 2 lacs, 3 lacs, 3 lacs+ per year. Salary in cash □ Yes No

6. Work Experience : Currently employed : □ Yes □No

Current Company __________________________________ Position ____________ Date _______/ __________
Past Company _____________________________________ Position ____________ Date _______/ __________
Yes No
7. IELTS/PTE/TOEFL. Overall score _______ R _______ W _______ L _______ S _______ Yes No
I will be giving IELTS/PTE/TOEFL on:
8. I have clear 1 year old funds available for studies & living for 1 year (with Source) Yes No

9. Only parents sponsoring my education Yes No

Total amount available: Rs _____________ Source of Income:
10. My parents/ sponsors are □ Agriculturists □NRI □Business □Service □Govt-Defence Yes No

□3 lac □3 lac+ per year)

11. Parents 3 year ITR available (Tick √: ITR amount : Yes No
Amount:
12. My Uncle/Aunty are sponsoring more than 30% my education. If yes, their Yes No
Total funds available with sponsor: Rs ________ lacs Source of income: _______________________
13. I am taking education loan: Amount – □Rs 7.5 lacs □10 □15 □20 □25 □30 lacs + Yes No
If yes, then Security for loan is:
14. I and/or my spouse had/have visa for Australia/ US/ UK/ Canada/ NZ – □ Student □Tourist □TR □PR Yes No

15. Have □ you or □spouse or □parents been refused any visa for Australia/ US/ UK/ Canada/ NZ – Yes No
□ Student □Tourist □TR □PR Reason for Refusal:

For Office Use only-

Received on ___________________________________________ Checked by _________________________________________ Date ___________________________

OK / Rejected If Rejected - Reason _____________________________________________________

Requirement _____________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________

Version: K.12.2018