Application Form

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Candidate Details
Name suraj kumar
Date of Birth 1999-05-23 Gender M
Father's Name baliram prasad Current Class XII Passed
Mother's Name sarita devi
Address sipara
City patna State Bihar
Pincode 800020
Mobile 8864005587 Mobile2 05587-8864005587

Registration and Purchase Details

User ID surajkumar91221@gmail.com Order ID 170342
Transaction
2017-06-22 11:35:39 Payment Mode online
Date/Time
Online Txn/DD No. JSM35446996881 Amount Rs 2200
Note: Enclose DD with this application in case payment mode is demand draft

Application No. Courses Purchased Course Code Scholarship Code Fee

Leader - Online Test Series for JEE Main
17651776 2122 N/A Rs 2200
2018

Declaration
I hereby accept that no refund will be made if I join ALLEN's Online test series by paying the prescribed fee.
I hereby declare that the information provided by me in this form are true to the best of my knowledge.
If I get selected in Pre-Medical Exams or Pre-Engineering Exams or Talent/Olympiad Exams or any Competitive
exams then ALLEN Career Institute can publish and display my name and photograph.
All disputes are subject to Kota (Rajasthan) Juridiction only.

Date: ______________ Place: ______________

Signature with date (Applicant) Signature with date (Father/Guardian)

Send the complete application form along with all required enclosures to the following address :
Administrator (E-learning Division)
ALLEN Career Institute
SANKALP, CP-6
Indra Vihar Phone: +91-744-5162-222 (10:00 AM to 08:00 PM)
Kota - 324005 Email: support@onlinetestseries.in
Rajasthan, India