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Candidate Details: Declaration Form

The document is a declaration form for an online GATE test series purchased by Ella Bhattacharya, providing her personal details like name, date of birth, father and mother's name, college details, and contact information. It also includes registration details like user ID, order ID, transaction details, course purchased and fee paid. The declaration section states that no refunds will be provided and agrees to publish achievements and display applicant details on the website.

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Evanora Java
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255 views1 page

Candidate Details: Declaration Form

The document is a declaration form for an online GATE test series purchased by Ella Bhattacharya, providing her personal details like name, date of birth, father and mother's name, college details, and contact information. It also includes registration details like user ID, order ID, transaction details, course purchased and fee paid. The declaration section states that no refunds will be provided and agrees to publish achievements and display applicant details on the website.

Uploaded by

Evanora Java
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Declaration Form

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Candidate Details
Application Form No. 17780010
Name Ella Bhattacharya
Date of Birth 1992-10-29 Gender F
Father's Name Sudev S Engg. Stream ECE
Mother's Name Dipasri B
College Jadavpur University
College City Kolkata
Mobile1 9836108181 Mobile2 033-23217793

Registration and Purchase Details


User ID shoppersstop777goodies@gmail.com Order ID 10303
Transaction
2017-04-09 19:59:46 Payment Mode online
Date/Time
Online Txn/DD No. IUPG5276406282 Amount Rs 370
Note: Enclose DD with this declaration form in case payment mode is demand draft

Courses Purchased Course Code Scholarship Code Fee


Combo Online Test Series for GATE (ECE) 2018 7099 GATEPT80 Rs 1900

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 the declaration form are true and correct to the best of
my knowledge.
I hereby agree that I will attach the photocopy of documents in support of Scholarship (if any).
ALLEN Career Institute can publish my achievements through GATE 2018 and display my details on website.
All disputes are subject to Kota (Rajasthan) Juridiction only.

Date: ______________
Signature (Applicant) Place: ______________

Send the complete declaration form along with all required enclosures to the following address :
Administrator (E-learning Division)
ALLEN Career Institute
SANKALP, CP-6
Indra Vihar Kota - 324005 Phone : +91-744-5162-222 (10:00 AM to 08:00 PM)
Rajasthan, India Email : gatesupport@onlinetestseries.in

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