1. Name of Applicant (In block letters as entered in 10th standard certificate)

2. Name of Parent/Guardian and relationship with applicant

3. Date of Birth

4. Gender Male Female Not Mentioning

5.Religion, Community Christian Hindu Jain Muslim Other Not mentioning		Caste
6.Category		Sub-category

7.Permanent Address

8.Address for Communication (mention if same as permanent address)

E-mail		E-mail
PIN		PIN
Phone (With STD)		Phone (With STD)
Mobile		Mobile

9.Father's Name		Father's Occupation
10.Mother's Name	Mother's Occupation

11. Annual Family Income

12. Name of Institution last Attended

13.Marks Obtained in 12th Standard for Mathematics, Physics, Chemistry, Biology/or its equalent

Subject	i) Mathematics	ii) Physics	iii) Chemistry	iv) Biology/alternate	Total	Year of Passing	Board
Mark Scored							CBSE ICSE State Other
Max. Mark

APPLICATION FEE PAYMENT DETAILS

Bank Name
DD No.
Date of Issue