Application Form

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Candidate Details
Name madhavrabin bipin
Date of Birth 2001-01-17 Gender M
Father's Name bipin Current Class X Undergoing
Mother's Name raniya
Address madhavam
City cherthala State Kerala
Pincode 688524
Mobile 9037961073 Mobile2 ______________

Registration and Purchase Details

User ID madhavrahulb@gmail.com Order ID 121410
Transaction Date/Time 2016-11-03 14:12:57 Payment Mode online
Online Txn/DD No. HHDF4872162224 Amount Rs 500
Note: Enclose DD with this application in case payment mode is demand draft

Application No. Courses Purchased Course Code Scholarship Code Fee

16657506 NSTSE 2017 Online Test Series for Class X 4155 N/A Rs 500

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 or any Competitive
exams then ALLEN Career Institute can publish and display my name and photograph.
All disputes are subject to Kota (Rajasthan) Juridiction only.

Date: ______________ Place: ______________

Signature with date (Applicant) 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