APPLICATION NUMBER :

200572
DETAILS OF CANDIDATE

Date : 28/09/2011

Name of the Candidate (As in 10th Class Certificate) : Nationality : Indian No R MANOHAR Person with Disablity :

RAKALA NANDINI Gender : Female Scribe Required : Category : GEN Date of Birth : 27/07/1991 Relationship : Father

Name of Father/Mother/Guardian:

CHOICE OF TEST PAPER [S] No. of Test Paper[s] Applied : 1 Session 1 : [CA] Computer Application CHOICE OF CITIES/TOWNS FOR THE TEST Choice of Cities/Towns for the Test First Choice : [101] Bengaluru Second Choice : [103] Hyderabad Session 2 :

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. 012098 Nationalised Bank Drawn On Central Bank of India SOURCE OF INFORMATION OF JAM 2012 I found out about JAM 2012 through : Friends/Seniors/Professors DETAILS OF CONTACT ADDRESS Name :
(DO NOT STAPLE)

Percentage of Aggregate Marks :

Other

Date 26/09/2011

Amount 800

RAKALA NANDINI 3-799, 1ST FLOOR, SRI SAI NILAYAM,EAST 3RD CROSS

Address :

Paste a Front Facial High Contrast Recent Colour photograph (3 cm X 4 CM) without any signature or attestation

GOPURAM ROAD PUTTAPARTHI State : Andhra Pradesh

Pin Code : 515134 Email : Phone : nandini.r@live.com 08555288832

Mobile No : 08879405989 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)

200572

BY REGISTERED POST/SPEED POST APPLICATION FORM

PAPER CODE EXAM CITY CA 101 103 To ORGANIZING CHAIRMAN, JAM 2012 INDIAN INSTITUTE OF TECHNOLOGY BOMBAY From
RAKALA NANDINI

POWAI, MUMBAI PINCODE 400076

3-799, 1ST FLOOR, SRI SAI NILAYAM,EAST 3RD CROSS GOPURAM ROAD PUTTAPARTHI Andhra Pradesh PINCODE 515134

APPLICATION NO

200572

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.