Academic Session: 2011-12

ORDER ID :

104503 11691563

ROLL NO. (StudentID) : (For Office Use)

STUDENT'S NAME : ARIJIT PANIGRAHY FATHER'S NAME : CATEGORY : GEN GENDER : Male RAJAT KUMAR PANIGRAHY

DOB : 28-February-1997 MEDIUM : E

TEST MODE: Online TEST CITY/CENTER : PROPOSED TEST CITY SCHOLARSHIP : CLASS : XI SPEED POST None None

PREFERRED COURIER :

CORRESPONDENCE ADDRESS MAILING ADDRESS :PRINICPAL, GOVERNMENT INDUSTRIAL TRAINING INSTITUTE , ENGINEERING SCHOOL ROAD. CITY/TOWN/TEHSIL/TALUKA : DISTRICT : STATE : PINCODE : Ganjam Orissa 760010 0860-2290761 BERHAMPUR

TELEPHONE NUMBER :

MOBILE NUMBER : 9438293909 PARENT'S MOBILE NUMBER PERMANENT ADDRESS MAILING ADDRESS :PRINICPAL, GOVERNMENT INDUSTRIAL TRAINING INSTITUTE , ENGINEERING SCHOOL ROAD. CITY/TOWN/TEHSIL/TALUKA : DISTRICT : STATE : PINCODE : Ganjam Orissa 760010 0860-2290761 BERHAMPUR 9040500208

TELEPHONE NUMBER :

MOBILE NUMBER : 9438293909 ACADEMIC RECORDS SCHOOL NAME CLASS : YEAR DAV PUBLIC SCHOOL BOARD : CITY BERHAMPUR

STATE Orissa MARKS(%) If You have qualified any of the competitive Exam as given above then you should send the photocopy of Selection Letter/ Score Card / Certificate of the same along with this form. Declaration : I hereby certify that the information given in the application form (as well as in all other relevant documents) is complete and accurate to the best of my knowledge and belief. I understand and agree that misrepresentatoin or omission of facts will justify the denial/cancellation of my adminision, or expulsion from the institute at any stage of the academic session. I have read and do hereby provide consent to the 'Terms & Conditions' and all relevant information as mentioned in Information Brochure for admission in the Institute for the Academic Session 2009-10. Further, if admitted, I promise to abide by the rules & regulations and norms of discipline of the institute as long as I remain a registered student of RESONANCE. I also declare that being an enrolled student of RESONANCE, I will be responsible to it in terms of providing relevant details of all the competitive examinations (in the form of true photocopies of the application form of the

relevant examination) that I will be appearing in the future by virtue of coaching & academic support from the institute. If I succeed in any of these competitive examinations, the institute will have all rights of using my result and photograph in any form for its growth strategies and developmental plans. In such a case, I'll never ever have any objection or protest for this. Signature (Student) Signature (Father/Guardian) Date: Place: Date: Place: Please Send the print out of this form at the Address given below (Three Photograph, 10th Marksheet, 12th Marksheet and Scholarship proof.) Edu Shoppee Fee counter, C-8, Lakshya, Nursery Plots, Talwandi, Kota (Raj.) Contact No. : 0744-3022244 / 3022245 (DLPD)| Fax No. : +91-022-391672228 Website : www.edushoppee.resonance.ac.in email : espayment@resonance.ac.in