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221091
DETAILS OF CANDIDATE
Date : 29/10/2011
Name of the Candidate (As in 10th Class Certificate) : Nationality : Indian No Person with Disablity :
NANDINI SHARMA Gender : Female Scribe Required : Category : GEN Date of Birth : 30/04/1991 Relationship : Father
Name of Father/Mother/Guardian:
DETAILS OF QUALIFYING EXAMINATION Qualifying Degree : B.Sc Qualifying Examination Passed : No Year of Qualifying Exam : CGPA (out of 10) : DETAILS OF DEMAND DRAFT DD No. 606546 Nationalised Bank Drawn On Punjab National Bank SOURCE OF INFORMATION OF JAM 2012 I found out about JAM 2012 through : Newspaper Advertisement DETAILS OF CONTACT ADDRESS Name :
(DO NOT STAPLE)
Other
Date 19/10/2011
Amount 1100
Address :
Paste a Front Facial High Contrast Recent Colour photograph (3 cm X 4 CM) without any signature or attestation
UTTAR PRADESH
State :
Uttar Pradesh
Mobile No : 09717752222 DECLARATION BY THE CANDIDATE: FULL SIGNATURE OF THE CANDIDATE(IN BLACK INK BALL-POINT PEN) 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 the information Brochure and I shall abide by the terms and conditions therein. In the event of suppression or distortion of any fact made in this application form, I understand that I will be denied the opportunity to appear in the JAM 2012, and if already appeared/ selected/ admitted, my admission/ degree acquired is liable to cancellation. Place : Date :
FULL SIGNATURE OF THE CANDIDATE (IN BLACK INK BALL-POINT PEN)
221091
APPLICATION NO
221091
PINCODE 201011
Uttar Pradesh
CHECK-LIST
1.Cut the above address slip along the dotted line and paste the address slip on the envelope containing your completed application form with your photo pasted on it and your two signatures. You must write your name and application number at the back side of the photograph before pasting it within the box provided in the application form. 2.You must enclose the attested copies of all relevant certificates (SC / ST / PD / Affidavit for change of name, if applicable) and the demand draft in the envelope. 3.Send the envelope by speed / registered post only. Application sent by courier will be rejected.