EOR Q-FIE
UGOETHE
Examination Registration Form
CAPITAL LETTERS
INSTITU
CUstomer Number 0 06 |9 2 1 4 5 Date of the Exam1nation 2ole1 24.
Examination
DFIT 1 DA2 FIT GZA1 SD1 XZ A2
GZ B1 OCZ B2 DGZ C1 DGZ C2- GOS
Module (B1, B2, C1& C2 GZ Exam)
U Horen/Listening
DLesen/Read1ng Schreiben/Wwritng Sprechen/Speaking
First Name
Last Name
Date of Birth (0D/MM/YYY 2qlb7| 20o 3 Place of Birth Chena
Purpose of learning the Language:
Higher Education in Germany Family reunion in Germany
Business in Germany Others -Please specify
Address for communication Plot No 3A, 18 bos. Bhakthavdn 8haet
Ambatti? Chaw bco os3
Mobile No. USooo 67bb EMail muta ai ab seuth194 0gnal- Con
Iam interested to get information on a regular basis about upcoming courses and examinations. YES NOX
Payment details:
Name of the Account Holder
Bank Name Amount Transferred 1D,boo/
NI6824309 8394 R3o
Date of Transaction Iblobl 24 Transfer / Reference No
Ihave read the terms and conditions and accept the same.
DATE 15lo6l 24 Signature
FOR OFFICE
GOETHE
INSTITU
MAX MUELIER
BHAVAN
Declaration of consent concerning data security
Examinations conducted by Goethe-Instituts are recognized as a proof of language ability in the neW
Immigration Act for reunifcation of spouses in the visa process. In order to check the genuinenesS of the
iSSUed examination certihcates while visa is being processed, the authorities concerned from the Ministry Of
External Affairs have to obtain Name, Examination results and the certificate numbers of such examinees wno
have appeared and passedthe exams for the visa purpose.
By signing this declaration of consent for data security the examinee declares that he/she agrees to tne
passing of his / her personal data to the concerned authorities from the Ministry Of External AffairS. Ihe
examinee can revoke his / her declaration of consent for data security to be effective in the future.
The declarationof consent 0S voluntarily given on one's own accord. If the consent is not given or revOked, tne
authorities from Ministry Of External Affairs cannot check the genuineness of the Examination certificate with
data available from Goethe Institut. In such cases the onus of proving the validity of the certificate lies
entirely on the visa applicant.
With this in mind the examinee declares the following:
Hereby I,
Sutel Hutboiad alainf pan
(First name and Last name)
Give permission to Goethe-Institut, Chennaito forward my personal data of theexamination appeared by me
SUch as my Name.my Examination result, the certificate number to the German Embassy / German Consulate
in India for counter checking for visa processing.
Uamai, 16)obl24
Place, Date Signature
Please note:
" The examination fees are nonrefundable
" Kindly be at the center 45 minutes before the start of the exam
" All candidates must carry any ONE original lD proof for the exam
(Passport, Driving License,Voter's ID. PANCard, Aadhar Card with complete Date of Birth)
