ca form 2013

1/27/13 CPT MAIN

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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: [email protected] 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


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


1/27/13 CPT MAIN


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ca form 2013

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