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Application Number:
Name of The Candidate: DOB: Sex: Category: State of Domicile: arent!s" #uardians phone no: arent!s" #uardians email id: City of examination: Are you employed $: arent!s"#uardian!s %ncome: Self %ncome:

12439 MR SAMBIT PATRA !"2#"19$$ Male %eneral &'is(a 9$!3224$#$ 'estine')*b+,mail)com B(ubanes-ar N ) )

Present A''ress
Address &: Address ': City: Country: State: District: incode: (obile: )mail:

P.&T N&/12"B0 1A2AD3R%A NA%AR B43BAN5S6AR In'ia &'is(a 7or'(a #!1 8

9132#$#!2# sambit2tos(iba+,mail)com

Permanent A''ress
Address &: Address ': City: Country: State: District: incode: (obile: )mail:

P.&T N&/12"B0 1A2AD3R%A NA%AR B43BAN5S6AR In'ia &'is(a 7or'(a #!1 8

9132#$#!2# sambit2tos(iba+,mail)com

9uali:;in, 5<amination Details

*a+e you passed bachelor!s degree $: 2es

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Applicant Details

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Degree: Degree /ualifying 0ear: Degree pattern: )ducation faculty: Speciali1ed Sub2ects: 3ni+ersity"College: lace: A+erage 4 (ar5s: Are you a post6graduate $:

B5"B)Tec( 2 11 1 =2=4 5n,ineerin, 5.5>TR&NI>S AND T5.5>&MM3NI>ATI&N BP3T B43BAN5S6AR $1)# No

Pro,ram Selection Details

7ocation &: rogramme &: reference &: ayment (ode: Mumbai M)A) 4uman Resources Mana,ement an' .abour Relations 1

online

Candidate Signature

Attac(ments
To +ie8 your %ncome certificate for the 9inancial 0ear '.&'6'.&: Clic5 here. To +ie8 your (ar5sheet of the last exam passed Clic5 here.

,ersion -.....'

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