bazm-e-niswan2011application - SECAB

CONTACT DETAILSFull PostalAddress( in CAPITALletters)PINCODE : Taluk : District :Phone No. (with STD Code) : Mobile No :Email ID :All attachments listed below are compulsory. Please put a tick () in the brackets to indicate the documentsyou have attached. Kindly do not attach any original documents.Xerox copy of SSLC / 10 th Marks Card : ( )Xerox copy of 2 nd PUC / 12 th Marks Card : ( )Xerox copy of CET 2011 Hall Ticket : ( )Xerox copy of CET 2011 Marks Card # : ( )Xerox copy of Address proof document * : ( )Xerox copy of Study Certificate : ( )Xerox copy of Caste & Income Certificate : ( )Note : # Internet Printout of CET results. * Ration Card or Electricity Bill or Water Bill or Identity Card.DECLARATION BY THE STUDENT AND PARENT/GUARDIANPlease paste here(do not staple )recent colorPassport sizePhotograph I hereby agree that all details furnished by me in this form are TRUE. I have not modified /manipulated any details. In case the particulars furnished are found to be incorrect, the organizationcan initiate suitable legal action against me.I shall report to the organization as and when decided by the organization and update about mystudies and career. I assure that I shall pursue my studies very seriously and become an asset for thecommunity and country._________________________________Date : __________________ Signature of the StudentPlace: ___________________________________________________Signature of the Parent/GuardianWhere to submit the filled in application form ?Filled in application forms must be submitted in person or sent through post or courier on orbefore 10 th June 2011 to the below address only.Bazm-E-Niswan Charitable Trust (R)No.37, Muniswamy Road, Tasker Town, Bangalore - 560051. Phone: 080-2286 0023 / 2286 5231PES 2011 P a g e | 3