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THE INSTITUTE OF CHARTERED ACCOUNTANTS OF INDIA - COMMON PROFICIENCY TEST - JUNE, 2016

Name of Candidate : ADITYA SHIVKUMAR NAIR


Gender : MALE

CPT Reg. Date : 29/07/2015 Revalidation Date : Nil Date Of Birth : 06/03/1998

E Mail : nair.aditya30@gmail.com

Control No:

710387

Registration No:WRO0581679

Center Selection

Mobile No : 9673670034 Landline No : -

Region : WESTERN REGION

Father's Name : SHIVKUMAR NAIR

Centre :THANE - III

Question Paper Booklet Language : ENGLISH

PIN :1998 Centre Code: 149

Address SHIVPUJA PALACE


203 DUSCHAWL ROAD,

Details of Latest Previous appearances in CPT :

ULHASNAGAR

MM : YYYY : Roll No.:

ULHASNAGAR - 421004
MAHARASHTRA , INDIA

ACADEMIC DETAILS OF QUALIFYING EXAMINATION (I.E., 12TH CLASS EXAMINATION) : ALREADY APPEARED

Year : 2016

Roll No : M170470

% of Marks secured in 12th class Examination :

Board of qualifying examination (i.e., 12th Class examination or equivalent) : STATE BOARD
Payment Details

Transaction Date:

08/04/2016

Amount: 500 INR

Bank Transaction No : EFC_WRO0581679_1140729442

DECLARATION BY THE STUDENT


I ADITYA SHIVKUMAR NAIR Son/Daughter of SHIVKUMAR NAIR hereby declare that I have not already passed CPT examination in any earlier attempt and request for permission to
present myself at the Common Proficiency Test conducted by the Institute of Chartered Accountants of India. I further declare that the particulars stated in this application form are true
to the best of my knowledge and belief. I have read the Guidance Notes for candidates and satisfied myself that I am eligible to appear in ensuing CPT to be held in June, 2016 and I
shall abide by the terms and conditions contained therein. I understand that my admission to CPT and result thereof shall be provisional and subject to verification of my fulfilling the
eligibility requirements in terms of Regulation 25D (as explained below) of the CA Regulations, 1988 and decision of the Council of ICAI. In the event of suppression or distortion of any
fact made in this application form, I understand that I shall be denied the opportunity to appear in CPT and if already admitted / appeared, my admission / result acquired shall be
liable for outright cancellation. I also understand that the decision of the Institute in this regard shall be final and binding upon me and I shall abide by the same.
Date:

_____________

Sign of Candidate:

______________________________

Sign of Parent / Guardian:

______________________________

Candidate's photograph

Candidate's photograph

Paste firmly with glue or

Paste firmly with glue or

adhessive like fevicol


(Do not staple) recent color
photograph of size 3.5 X
4.5 cms

adhessive like fevicol

Signature of the Candidate

(Do not staple) recent color

(Sign within the box with blue/black pen

photograph of size 3.5 X

only in the same style as signed in the

4.5 cms

CPT course Registration Form)

ATTESTED PHOTO OF CANDIDATE

Dated : 08/04/2016

NON ATTESTED PHOTO OF CANDIDATE

I do hereby certify that the photographs affixed above are that of MR./MS ADITYA SHIVKUMAR NAIR Son/Daughter of SHIVKUMAR NAIR, who has signed in my presence. I have
verified and satisfied that the candidate named above is registered for CPT course with the Board of Studies of the Institute on or before 1st April, 2016 and has already
passed/already appeared / will be appearing in 12th class examination in April/May, 2016 and is eligible as per Regulation 25 D (as explained below). The particulars as furnished
have been verified by me and found correct with reference to the documents produced before me by the candidate.

Name and membership No.of the Member of ICAI /Head of

Date:
Place:

the Educational Institution /Gazzetted Officer with Seal


Signature of Member of ICAI/Head of Educational Institution /Gazzetted Officer

Tel No._________________________

Important: Please do not fold this document while posting


Explanation of Regulation 25 D:
1. The candidate should be registered for CPT course with BOS of ICAI on or before 1st April, 2016 and if registered on or before 1st April, 2013, he should have already
applied for revalidation of registration in terms of Board of Studies Announcement No. BOS/Announcement/227/13 dated 22nd January,2013 hosted on www.icai.org.
2. The candidate who has passed 12th class or equivalent examination or appeared in 12th class or equivalent examination or will be appearing in 12th class or equivalent
examination in April/May, 2016 will be eligible to appear in CPT exam to be held in June, 2016.

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