Water Pollucation

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Bangalore-560 090, India •Ph: +91-80-6451 7317, 2837 6431, 2839 6011 •Fax: +91-80-2370 0242 •E-mail: admissions@acharya.ac.in •URL: www.acharya.ac.in

ACHARYAHesaraghatta Main Road, INSTITUTES Soldevanahalli,

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Application No Name Admission Year


- 20


Program Applied xProgram applied for (In order of preference): 1. xInstitution applied for xPercentage of marks obtained at the Qualifying Examination Applicant’s Information xFull Name of the Applicant (in block letters) xNationality xDate of Birth: DD M Year Address for Correspondence of Applicant xPermanent Address of Applicant xSex: Male Female 2.

xe-mail xTelephone : Area Code Parent / Guardian Information xName of the Parent / Guardian xOccupation of Parent / Guardian xPermanent Address of the parent xSex: Male Female Number

xe-mail xTelephone : Area Code Additional Info xLocal Address of Applicant (if any, in Bangalore) Number

xBangalore Telephone Numbers Category xWhether the candidate belongs to SC/ST or BC/BT Yes xWhether the candidate is NRI/Foreign National Yes No No (Enclose copy of certificate if Yes) (Enclose Passport copy if Yes)

Academic Background Educational Qualification: Beginning from Name of Board the latest qualify- or University ing Examination passed / year

Name of the College Studied

Subjects Studied

Max Marks

Total Marks Scored


xLanguages studied: First Language Second Language Enclosures xDetails of copies enclosed: Tick the relevant boxes Degree Marks Cards 10th Std. Certificate Migration Certificate (For P.G.Course) Marks Cards of 10+2 or any other equivalent exam

Transfer Certificate Caste Certificate
(wherever applicable)

Conduct Certificate Any others

Declarations xDeclaration by the candidate I declare that the above information is true and correct to the best of my knowledge and belief. Place Date Signature of the Candidate xDeclaration by the Parent / Guardian...
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