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The Institute of Chartered Accountants of India - COMMON PROFICIENCY TEST - JUNE 2012

Name of Candidate : PALAK GOEL Gender :FEMALE CPT Reg. Date :30/03/2012 Date Of Birth : 05/01/1994 599306 Paste firmly with glue or adhessive like fevicol (Do not staple) recent color photograph of size 3.5 X 4.5 cms

E Mail :palak_sweett@yahoo.com Registration No : NRO0338832 Control No : Mobile No :9711574874 Landline No :011-25458674 PIN :6159

Question Paper Booklet Language : ENGLISH Father's Name :MANOJ KUMAR GOEL Address H NO- B-234 SHIVAJI VIHAR,NEAR RAJOURI GARDEN NEW DELHI - 110027 DELHI , INDIA Academic Details Qualifying examination (i.e., 12th Class examination) : ALREADY APPEARED Year of qualifying examination (i.e., 12th Class examination) % of Marks secured in 12th class Examination : 2012 :

Roll No of Qualifying Examination(i.e.,12th Class examination)

9186380

Board of qualifying examination (i.e., 12th Class examination or equivalent) : CBSE Center Selection : Region : NORTHERN REGION City :DELHI / NEW DELHI I Details of Latest Previous appearances in CPT : MM : YYYY : Roll No.: Payment Details Transaction Date: 24/04/2012 Amount: 500 INR Bank Transaction No: EFC_NRO0338832_1228774485

Declaration by the student I PALAK GOEL Son/Daughter of _______________________________________ request for permission to present myself at the Common Proficiency Test conducted by the Institute of Chartered Accountants of India. I hereby declare that the particulars stated in this application form are true to the best of my knowledge and belief. I have read the Guidance Notes for candidates and satisfied myself that I am eligible to appear in ensuing CPT to be held in June, 2012 and I shall abide by the terms and conditions therein. I understand that my admission to CPT and result thereof shall be provisional and subject to verification of my fulfilling the eligibility requirements in terms of Regulation 25D (as explained below) of the CA Regulations, 1988 and decision of the Council of ICAI. In the event of suppression or distortion of any fact made in this application form, I understand that I shall be denied the opportunity to appear in CPT and if already admitted / appeared, my admission / result acquired shall be liable for outright cancellation. I also understand that the decision of the Institute in this regard shall be final and binding upon me and I shall abide by the same.

Signature of the Parent/Gaurdian (Sign within the box with blue/black pen) Dated : 23/04/2012

Signature of the Candidate (Sign within the box with blue/black pen)

I do hereby certify that the photograph affixed above is that of MR./MS PALAK GOEL Son/Daughter of __________________________, who has signed in my presence. I have verified and satisfied that the candidate named above is registered for CPT course with the Board of Studies of the Institute on or before 4th April, 2012 and has already passed/already appeared / will be appearing in 12th class examination in March/April, 2012 and is eligible as per Regulation 25D(as explained below). The particulars as furnished have been verified by me and found correct with reference to the documents produced before me by the candidate. Date: Place: Signature of Member of ICAI/Head of Educational Institution /Gazzetted Officer Name and membership No.of the Member of ICAI /Head of the Educational Institution /Gazzetted Officer with Seal Tel No._________________________

Important: Please do not fold this document while posting Explanation of Regulation 25D: 1. The candidate should be registered for CPT course with BOS of ICAI on or before 9th April, 2012. 2. The candidate who has passed 12th class or equivalent examination or appeared in 12th class or equivalent examination or will be appearing in 12th class or equivalent examination in March/April, 2012 will be eligible to appear in CPT exam to be held in June, 2012.Refer Guidance Notes for latest Council decision.