APPLICATION FOR ADMISSION TO

ENGINEERING AND TECHNOLOGY

B.TECH COURSE 2017 - 18
APPLICATION NO: 1032547

Campus Preference

Specialization Preference

Preference 1

MAIN CAMPUS (KATTANKULATHUR,

CHENNAI AREA)

Preference 1

AEROSPACE ENGINEERING

Preference 2

NCR CAMPUS, DELHI

Preference 2

ELECTRONICS AND COMMUNICATION

ENGINEERING (ECE)

Preference 3

NCR CAMPUS, DELHI

Preference 3

COMPUTER SCIENCE AND ENGINEERING (CSE)

Preference 4

Preference 4

Preference 5

Preference 5

10+2 Studied in India?

YES

Exam Details (Test City Preferences)

Preference 1

ALWAR

Preference 2

ALLAHABAD

Preference 3

ALIGARH

Personal Details
Name

ABHISHEK UPADHYAY

Email Address

ABHISHEKU25802580@GMAIL.COM

Mobile No.

9452432284 Date of Birth

02/12/2000

Gender

MALE

Blood Group

O+

NO

Nationality

INDIAN

Physically
Challenged

Nature Of Deformity
Category

Percent Of Deformity
RESIDENT INDIAN

Residing Country

PIO Card Name

OCI Card Name

Communication Address
Address Line 1

G-111

Address Line 2

SHANTIPURAM

City

ALLAHABAD

Pincode

211013

State

UTTAR PRADESH

Country Name

INDIA

Family Details
Father's Name

ARUN KUMAR UPADHYAY

Mother's Name

NIRJALA DEVI

Occupation

GOVERNMENT SECTOR

Occupation

HOMEMAKER

Designation

CT/GD

Designation

Mobile No.

9452432284

Mobile No.

Email Address

ABHISHEKU25802580@GMAIL.COM

Email Address

7844982584

Academic Details

Institute

Xth

GYAN GANGA
INTERNATIONAL
ACADEMY
BHOPAL MP

Board
CENTRAL
BOARD OF
SECONDARY
EDUCATION

Register
No.

1187353

Status

No. of Attempt

Year of
Passing

03/2014

PCM
Overall
/
%/
PCB
Grade
%
82

XIIth

CENTRAL
BOARD OF
SECONDARY
EDUCATION

DELHI PUBLIC
SCHOOL
ALLAHABAD

APPEARING

APPEARING/APPEARED
FOR THE FIRST TIME

04/2017

Payment Details
Transaction ID

105166397062

Mode of Payment

Debit Card

Payment Method

Online

Payment Date

31/12/2016

DD Number

Bank Name

Branch Name

DD Date

Declaration
I certify that the information submitted by me in support of this application, is true to the best of knowledge and belief. I
understand that in the event of any information being found false or incorrect, my admission is liable to be rejected /
cancelled at any stage of the program. I undertake to abide by the disciplinary rules and regulations of the institute.
Applicant
Name

ABHISHEK
UPADHYAY

Parent
Name

ARUN KUMAR
UPADHYAY

Date 31/12/2016 Signature