Bangalore-560 090, India •Ph: +91-80-6451 7317, 2837 6431, 2839 6011 •Fax: +91-80-2370 0242 •E-mail: firstname.lastname@example.org •URL: www.acharya.ac.in
ACHARYAHesaraghatta Main Road, INSTITUTES Soldevanahalli,
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Application No Name Admission Year
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
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
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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