APPLICATION NUMBER 3146805 PAYMENT MODE CREDIT CARD

COURSE GROUP 34 AMOUNT 2000

COURESES/APPLIED [MTech/ME] DD NUMBER NA
TEST CENTER Bangalore,Manipal DD DATE NA
DATE OF BIRTH 01/6/1993 CATEGORY GENERAL
SEX Male NATIONALITY India
NAME OF THE APPLICANT CHANNAVEERA SHASTRY D.M
NAME OF THE PARENT/ SHIVAKUMAR D.M
GUARDIAN
ADDRESS LINE 1 19.TERUBIDI HOUSES NAYAKARA ONI
ADDRESS LINE 2 YELUBENCHI POST
ADDRESS LINE 3 BALLARI DISTIC & TALUK
PIN 583101 STD CODE/TELEPHONE NA
NUMBERS
CITY Ballari E-MAIL ADDRESS channaveerashastry@g
mail.com
STATE Karnataka MOBILE NUMBER +917204593409
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 Academy of Higher Education, Manipal - 576104