Name (In block letter as in S.S.L.C Book)

Expansion of initials

Mobile

Address to which communications are to be send with pin code & Phone No.

Permanent address with pin code & phone No

Name of the institution in which the applicant studied for the Qualifying Exam

No. of chances taken to pass QUALIFYING EXAM

Details of marks (Attach self attested copy of marks)

Course to which admission is sought

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