Application Form

Affix latest
passport size
color
photograph

Candidate Details

Name
Date of Birth
Father's Name
Mother's Name
Address
City
Pincode
Mobile

Rupsa Bhattacharya
1999-06-02
Swapan Bhattacharya
Minati Bhattacharya
New Barrackpur
Kolkata
700131
9433833894

Gender
F
Current Class XII Undergoing

State

West Bengal

Mobile2

______________

Registration and Purchase Details

User ID
raitinni131@gmail.com
Transaction Date/Time 2016-06-19 18:43:08
Online Txn/DD No.
GSMP4554376257
Note: Enclose DD with this application in case payment
Application No.

16650697

Order ID
95572
Payment Mode online
Amount
Rs 2800
mode is demand draft

Courses Purchased

Leader - Online Test Series for NEET-UG

2017

Course Code Scholarship Code

3122

N/A

Fee

Rs 2800

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 then ALLEN
Career Institute can publish and display my name and photograph on its website.
All disputes are subject to Kota (Rajasthan) Juridiction only.
Date: ______________

Signature with date (Applicant)

Place: ______________

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 07:00 PM)
Kota - 324005
Email: support@onlinetestseries.in
Rajasthan, India