ca form 2013
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1/27/13 CPT MAIN
www.icai.org/frmaxisfeeresponse.html?vpc_3DSECI=05&vpc_3DSXID=R9tgEWDJqFvuzwpVr891AiT9zKQ%3D&vpc_3DSenrolled=Y&vpc_3DSstatus=Y&vpc_… 1/5
Acknowledgement No.: ACKC11147871
Application Form for Registration to Common Proficiency Test Course
1.Name in full (As per SSC X certificates)
First Name: Rohit
Middle Name:
Last Name: Mittal
2.Sex: Male
3.Date of Birth: 11-02-1995
4.(a)Mother's Name: Sangeeta Mittal
4.(b)Father's Name: Rajesh Mittal
5.(a)Address For Communication:
Address Line 1: 30, bazar lane bhogal
Address Line 2:
Address Line 3:
Address Line 4:
City: NEW DELHI State Code: DELHI
Pin: 110014 Phone No. with STD Code: 01124374975
Country: INDIA
Email id: rmrmittal2@gmail.com Mobile No.: 9654172577
5.(b)Permanent Address Same As Communication Address given in 5(a) above: Yes
Address Line 1: 30, bazar lane bhogal
Address Line 2:
Address Line 3:
Address Line 4:
City: NEW DELHI State Code: DELHI
Pin: 110014 Country: INDIA
Please fill the circle as applicable: (Enclose proof thereof)
6. Category Gen
7. Nationality: Indian
8. Medium of study: English
9.Details of Educational Qualifications: Starting from 10th standard
1/27/13 CPT MAIN
www.icai.org/frmaxisfeeresponse.html?vpc_3DSECI=05&vpc_3DSXID=R9tgEWDJqFvuzwpVr891AiT9zKQ%3D&vpc_3DSenrolled=Y&vpc_3DSstatus=Y&vpc_… 2/5
Examination Board/Authority YearResult
Marks Obtained Max Marks Awaited
10th CBSE 2011 6 10
12th Yes
Degree Yes
Diploma Yes
10. Annual income of Parents: INR 400000
11. In case an existing student of Professional Education (Course-I/II)wants to switch over to CPT, please provide your Unique RegistrationNo.(i.e.,WRO/SRO/NRO....)
12. India National residing in India Rs.6100/-
13.No Subscription for Student's Journal No Subscription for Member's Journal
Total Amount Paid: 6300
Declaration
I hereby declare that the information furnished herein above is true to the best of my knowledge.
Date: 27-01-2013
Place: New DelhiSignature of applicant
Name _______________________________________
1/27/13 CPT MAIN
www.icai.org/frmaxisfeeresponse.html?vpc_3DSECI=05&vpc_3DSXID=R9tgEWDJqFvuzwpVr891AiT9zKQ%3D&vpc_3DSenrolled=Y&vpc_3DSstatus=Y&vpc_… 3/5
1/27/13 CPT MAIN
www.icai.org/frmaxisfeeresponse.html?vpc_3DSECI=05&vpc_3DSXID=R9tgEWDJqFvuzwpVr891AiT9zKQ%3D&vpc_3DSenrolled=Y&vpc_3DSstatus=Y&vpc_… 4/5
1/27/13 CPT MAIN
www.icai.org/frmaxisfeeresponse.html?vpc_3DSECI=05&vpc_3DSXID=R9tgEWDJqFvuzwpVr891AiT9zKQ%3D&vpc_3DSenrolled=Y&vpc_3DSstatus=Y&vpc_… 5/5
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