APPLICATION NUMBER 3663419 PAYMENT MODE CREDIT CARD

COURSE GROUP 2 AMOUNT 2000

COURESES/APPLIED [BTech] DD NUMBER NA
TEST CENTER Delhi,Noida DD DATE NA
DATE OF BIRTH 11/12/1999 CATEGORY GENERAL
SEX Male NATIONALITY India
NAME OF THE APPLICANT Bhuvesh Kaushik
NAME OF THE PARENT/ Divya Kaushik
GUARDIAN
ADDRESS LINE 1 E-66
ADDRESS LINE 2 Shastri Nagar
ADDRESS LINE 3 Ghaziabad
PIN 201002 STD CODE/TELEPHONE NA
NUMBERS
CITY Ghaziabad E-MAIL ADDRESS bhuvesh011@gmail.com
STATE Uttar Pradesh-NCR MOBILE NUMBER +919953249906
DATE OF COMPLETION OF NA
INTERNSHIP
EXAM REG NUMBER NA EXAM ROLL NUMBER NA
EXAM NAME NA EXAM SCORE NA
EXAM RANK NA
FOR MD/MS FOR MTECH
APPLICANTS APPLICANTS
ARE YOU A DIPLOMA NA ARE YOU A GATE SCORER? NO
HOLDER?

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